Introduction BASHH, GMC, RCP and FSRH provide guidance stating that a chaperone should be offered for intimate examinations and the name of the chaperone should be documented. Record keeping is often found to be suboptimal in litigation. Our proformas have prompts for both offer and name of chaperone.
Aim/objectives To audit our documentation of chaperone offer (including name) for intimate examinations.
Methods 20% case notes for new episodes seen by doctors May–July 2014 were randomly selected and reviewed. Gender of doctor and patient were recorded.
Results 208 case notes were examined. 114 patients were examined (61 not examined; 33 inadequate documentation). 96/114 (84.2%) had the offer of a chaperone documented; 18 (15.8%) did not. Of the 96 where the chaperone was documented as offered, 89 (93%) had the chaperone’s name documented; 7 (7%) did not. In 64 cases, doctor and patient were the same gender, and in 50 cases they were opposite gender – chaperone offer was documented in 87.5% and 80% respectively (p = 0.278, student’s 2 tailed t-test).
Discussion Chaperones for intimate examinations reassure and protect both doctors and patients. With the GMC dealing with just under 30 allegations in 2014 recording of this is potentially pivotal. Despite prompts, only 78% had both offer and name documented. It was concerning that in 33 cases it was not clear as to whether or not an examination had occurred. The results ran counter to expectations with offer of a chaperone higher when patient and doctor were the same gender although this was non-significant.
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