Abstract
We performed an audit at the Edinburgh Chalmers Sexual Health Centre to examine if the use and documentation of chaperones complies with the guidance set out by the General Medical Council (GMC) and other regulatory bodies. The case-notes of patients seen in the non-specialist, morning clinics over a one-week period were studied. Only 20 of the 104 genital examinations undertaken were recorded as chaperoned. Only in five of the unchaperoned examinations was it documented that a chaperone was declined. Thus, a total of 24% patients had documentation regarding the presence of a chaperone or the offer of one. However, these results show that our department is certainly lacking in documentation of this, if not the use of chaperones itself. This falls short of the GMC guidance for good practice: primarily in place not only to protect patients from harm, but also to safeguard clinicians against false accusations of impropriety.
INTRODUCTION
In the UK, the General Medical Council 1 (GMC), the Royal College of Physicians of London Joint Specialty Committee for Genitourinary (GU) Medicine 2 and the Faculty of Sexual and Reproductive Health (FSRH) 3 all have issued guidance on the use of chaperones for intimate examinations. All these guidelines advise the offering of chaperones for genital examinations, irrespective of the gender of the examining clinician. Furthermore, they recommend documentation of the outcome of the offer and, if accepted, the chaperone's identity. 1,3 A chaperone is present as a safeguard for both patient and practitioners and is a witness to continuing consent of the procedure. 4
We undertook an audit at the Edinburgh Chalmers Sexual Health Centre (offering integrated GU medicine and sexual and reproductive health services), to examine if the use and documentation of chaperones in our general (non-specialist) clinics complies with UK guidance.
METHODS
All the patients who were seen at a general integrated sexual health clinic at the Edinburgh Chalmers Centre, on the mornings of 5–9 September 2011, were included in the audit. Most were new patients, but some were follow-up appointments.
The electronic case notes of the patients who attended the above clinics were studied, and patients who received genital examination selected for further analysis. Data were collected on: patient demographics, primary reason for attendance, reason for genital examination, documented offer of a chaperone and outcome of offer. In addition, details were recorded on the gender and discipline of the examining clinician.
RESULTS
Only 175 patients attended consultations during the audit period. Of these, 104 patients (56 men and 48 women) received genital examination and their notes were further analysed. Patient median age was 27 years (15–74), and majority were Caucasian (73, 70%). Among the male patients, 14 (25%) were men who have sex with men (MSM).
Of the 104 genital examinations performed, a majority 86 (83%) were for patient symptoms, nine (9%) for cervical smear taking and seven (7%) for intrauterine device (IUD) insertion/review (some examinations occurring for multiple reasons). Ten (10%) of the genital examinations were performed for other reasons, including swabs for routine sexually transmitted infection screens in MSM and gonococcal cultures.
Comparing documentation of chaperone use with gender of patient
From the audited clinics, only two genital examinations (one male and one female patient) were performed by a male clinician. Neither examination was documented as either having a chaperone or receiving the offer of one. Of the 102 genital examinations undertaken by female clinicians, 30% (14/47) of examinations on female patients were chaperoned, compared with just 11% (6/55) of examinations on male patients. However, a further five (9%) male examinations undertaken by female clinicians had a chaperone offer documented.
Similar percentages of genital examinations performed by medical and nurse practitioners were chaperoned; 19% (16/86) and 22% (4/18), respectively. Of the unchaperoned examinations, none performed by a nurse had a chaperone offer documented, while 7% (5/70) of those undertaken by a medical practitioner did.
DISCUSSION
The purpose of the GMC is to ‘protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine’. As expressed by both the GMC and specialty specific guidelines, there are numerous benefits of a chaperone for intimate examinations: primarily the further explanation and re-assurance to patients, and safeguarding them from actual or perceived abuse by the examining clinician. 1,5 Chaperones must be adequately trained, so they can understand the examination and therefore identify unusual or unacceptable behaviour by the clinician. 4
Another significant benefit is the safeguarding of clinicians against false accusations of impropriety. 3,5 A chaperone is a witness to the patient's continuing consent throughout the procedure. It is very rare for a clinician to receive an allegation of assault if they have a chaperone present. 6 Chaperones can also be of great practical assistance during the examination or associated procedures, 3,5 increasing clinical efficiency: this likely explains the finding that that 71% of patients receiving genital examination for IUD insertion/review were chaperoned, compared with only 15% of those examined because of symptoms.
Despite the above described benefits, a significant majority of the genital examinations reviewed were performed without a chaperone. These results are not dissimilar to reports from units elsewhere. 7–9 A possible explanation comes from the results of numerous studies demonstrating that, even when offered, a majority of patients decline the offer of a chaperone 9–11 and some patients report being uncomfortable with the presence a third party during an intimate examination. 12,13
While it is entirely appropriate to undertake an unchaperoned examination if the patient declines a chaperone, GMC guidance urges the offer to be clearly documented, a requirement that we failed. Our department's electronic patient record (EPR) has a separate page for examination, containing a tick-box for recording chaperone offer, outcome and identity. However, examinations are often only recorded in the final clinical note, and chaperone documentation is missed here. We are now re-addressing this shortcoming through staff education about the importance of chaperoning and thorough documentation. Changing the EPR set-up is difficult, but will be discussed with the IT department; if it is possible to make the chaperone box mandatory this would give electronic records a significant advantage over written ones, since a lack of adequate record keeping leaves the clinician significantly more vulnerable to litigation, as well as falling short of recommendations for good medical practice.