Sensitive Exams Policy Development and Implementation Toolkit

This toolkit, developed by the ACHA Best Practices for Sensitive Exams Task Force, includes three main components: policy development, implementation, and resources.

The full toolkit is available here, or use the links below to access specific collections of resources.

Policy Development

All institutions that provide sensitive exams should have a written policy that includes:

Definition of Sensitive Exam, Near Sensitive Exam, and Chaperone


  • Role of Chaperones
  • Chaperone Training
  • Provider and Staff Training
  • Patient Education
  • Reporting of Non-Compliance and Complaints
  • Risk Management Related to Investigation of Complaints

The following text and examples from the ACHA Guidelines: Best Practices for Sensitive Exams, published October 2019, can help inform the development of your policy.

ACHA recommends an opt out policy. Included in this toolkit are examples of opt out, mandatory, and opt in with formalized consent policies. You should be aware of state law regarding chaperone use prior to developing your institutional policy. Click the button below for a variety of examples.

Policy Examples and Legal Considerations

Definition of Sensitive Exam, Near Sensitive Exam, and Chaperone


Sensitive Exam: A sensitive exam or procedure includes, but is not limited to, an exam, evaluation, palpation, physical therapy for, placement of instruments in, or exposure of genitalia, rectum, or breast.

Near Sensitive Exam: A patient’s personal and cultural experiences may broaden their own definition of a sensitive exam or procedure. Some patients may include in their definition of a sensitive exam an examination or procedure that involves partial exposure or palpation of body parts near sensitive areas (e.g. exposure of undergarments, palpation of the groin or buttocks, or auscultation near the breast), and a chaperone should be offered.

Chaperone: A chaperone is a trained person who acts as a support and witness for a patient and a provider during a sensitive exam or procedure. If properly trained to do so, they may also assist the provider with equipment and specimen handling. However, these responsibilities should not detract from their ability to support and witness important aspects of the examination. A chaperone is utilized to help protect and enhance the patient’s comfort, safety, security, and dignity during a sensitive exam or procedure. The chaperone may be a provider or a trained staff member. Whenever possible the patient should be allowed to request the gender of the chaperone. A family member or support person may be present during a sensitive exam or procedure if it is the expressed desire of the patient but cannot serve as a chaperone.

Role of Chaperones

A chaperone is a trained person who acts as a support and witness for a patient and a provider during a sensitive exam or procedure.

Chaperones should be able to provide critical input during an exam based on the needs of the patient, as well as feedback after an exam without coercion, fear of retaliation, or reprimand. Therefore, chaperones should not report directly to the provider, or to the direct supervisor of the provider when possible.

The chaperone should also not be subject to academic evaluation; therefore, it is not recommended that medical students or other health care trainees serve as chaperones.

Chaperone Training

Training of both chaperone and provider should review expectations for each role, improve communication between the team, suggest neutral terms for intervention in the case of patient distress or chaperone discomfort, and set expectations for provider behavior and procedure.

A portion of the training for the chaperone must include how to report unprofessional conduct during the medical exam or concerns about violation of the chaperone policy.

Training should occur at hire or when someone is designated as a chaperone and renewed regularly with knowledge/skill competency to include cultural sensitivity and trauma-informed practices.

Below are key components to be included in chaperone training:

  • Ensuring patient comfort during exam

  • Ensuring patient dignity with privacy for dressing/undressing and appropriate gown or drape

  • Informing patient that chaperone will be present if a sensitive exam is performed or for any other exam as requested by the patient or provider

  • Documenting chaperone presence during exam or declination of chaperone by patient

  • Positioning of chaperone during exam to visualize point of contact of exam or procedure

  • Assisting other staff with dressing/undressing and toileting before or after examination. Two staff, one of which is a chaperone, should be provided to patients who require such assistance.

  • Reviewing how chaperone may intervene or stop an exam if they are concerned about patient distress or inappropriate steps during the exam

  • Reviewing reporting mechanisms for concerns or non-compliance with policy

Provider and Staff Training

Training of both chaperone and provider should review expectations for each role, improve communication between the team, suggest neutral terms for intervention in the case of patient distress or chaperone discomfort, and set expectations for provider behavior and procedure.

Training should occur at hire and renewed regularly to include cultural sensitivity and trauma-informed practices. Below are key components to be included in provider training:

  • Communication with patient about why the sensitive exam is needed

  • Appropriate communication before and during sensitive exams to explain what will happen throughout the exam

  • Education to reinforce the importance of minimizing the amount of sensitive information asked and shared in front of the chaperone to protect patient confidentiality

  • Chaperone communication to signal the need to pause exam due to obscured view or patient discomfort

  • Respecting a patient’s decision to refuse a chaperone while also acknowledging a provider’s right to refer that patient to another health professional or clinic if the provider is not comfortable completing the sensitive exam without a chaperone.

  • Resources for patient education

  • Documentation if patient declines any part of exam

  • Documentation of consent for photographs of sensitive areas

  • Provide two staff, one of which is a chaperone, for patients who need assistance with dressing/undressing or toileting before or after an exam.

Patient Education

Prior to the exam, it is important to educate the patient as to why the examination is needed, what the exam entails, the purpose and availability of a chaperone, and importantly, the patient’s ability to decline or stop any portion of the exam.

Best practice recommendations should include:

  • Provision of materials outlining the components of a sensitive exam, the role of a chaperone, and how to report concerns about inappropriate exams or violations of the policy

  • Expectation that a chaperone will be present for a sensitive medical exam and available for any other exam upon patient request

  • Ability of a patient to request the gender of a chaperone

  • Verbal explanation of the planned examination by a provider

  • Education on the patient’s right to request further clarity on the exam, express discomfort, or to terminate an exam at any point

  • Provision of adequate privacy to undress/dress with appropriate gowns/drapes to afford patient dignity

Reporting of Non-Compliance and Complaints

All reports and complaints should be evaluated through a process developed by each institution to ensure a timely investigation, quality assurance, and quality improvement.

Chaperone policies should include processes for patients, chaperones, clinic staff, and providers to report concerns of suspected noncompliance and policy violations.

Because of power differentials inherent in clinical care and resultant disincentives for reporting, reporting lines of authority should be distinct from employment and clinical supervisory hierarchy.

Multiple processes should be developed to minimize disincentives for patient reporting and should be included in patient education materials at each visit, including an anonymous reporting option.

Reporting of Non-Compliance and Complaints

Polices should be reviewed and approved by the institutional general counsel, and for those institutions affiliated with academic medical centers, the procedural and response policies of both organizations should be closely aligned.

Organizations should include within their policies guidelines for the appropriate response to reports of non- compliance with the guidelines and must investigate allegations of suspected unprofessional behavior by providers. Institutions must be cognizant of state law, especially those concerning minors.

Key components for consideration:

  • Timely investigations of suspected inappropriate behavior should be conducted by an impartial external office (e.g., Title IX, Office of Equity and Inclusion, campus law enforcement, medical ethics review board).

  • Results of external investigations should be reviewed by institutional general counsel, outside counsel hired specifically for the investigation, or a human resources team and should be shared with the governing body of the organization for corrective action as indicated.

  • Organizations should retain objective and subjective comments received regarding provider interactions with patients (e.g., patient comments, patient satisfaction survey data), which may be useful as part of investigations in demonstrating patterns of behavior.

  • Understanding that being the subject of an investigation may be a traumatic experience, institutional support resources should be made available to providers or chaperones during an investigation. If a patient is the complainant, they should be made aware of campus support resources such as the sexual assault resource center or counseling center.

  • To respect the integrity of the investigative process and those involved, all inquiries related to a complaint should be directed to public affairs and general counsel for advice. In accordance with HR policies, the nature of the complaint and the names of the involved parties should remain confidential.

Policy Implementation and Resources

After developing policy, focus should be placed on creating a timeline for development and implementation. The timeline should account for securing necessary resources and funding for implementation. Components of the implementation process may include determining staffing needs, developing materials for chaperone, provider and staff training, and materials for patient education. Institutions must have protocols and educate staff and patients on reporting of non-compliance and complaints. Investigation of complaints and allegations of misconduct should be addressed in accordance with your institution’s policies on grievance and sexual misconduct.

The following resources are provided for your consideration. The American College Health Association does not endorse any particular program or resource. The resources provided are not meant to be a finite list. Rather, this list should be regarded as a sampling of some of the many resources available to assist institutions of higher education with addressing sensitive exams.

New and updated resources are continually available. It is imperative for institutions to remain vigilant of new resources and their content.

Timeline

Development and implementation of a policy can be a lengthy process. Plan for obtaining resources and developing education and training. See examples of timelines and workflows by clicking the button below.

Policy Implementation Road Map

Chaperone Training

All chaperones should receive training prior to performing this role and on a regular basis. Following the completion of training, chaperone skills should be assessed, and competency recorded. See written examples, training presentations, and videos by clicking the button below.

Chaperone Training Resources

Provider and Staff Training

At hire and on a regular basis, all providers and staff should receive role-specific training on sensitive exams; patient, provider, and chaperone rights and responsibilities; and reporting policies and procedures. See written examples, training presentations, and videos by clicking the button below.

Provider Training Resources

Patient Education

Patients should be educated on the indications for and elements of the exam or procedure, the purpose of the chaperone role, and their right to decline or stop any portion of an exam. Patients should be informed of their right and the process for reporting any concerns. See sample patient educational materials by clicking the button below.

Patient Education Resources

Reporting and Risk Management

It is critical that all involved parties receive training and be made aware of mechanisms for reporting. An institutional culture that supports protections and rights for all should be fostered. Chaperones and those reporting concerns should be protected from retaliation. Any form of retaliation should be reported according to your institution’s policies. When there is a complaint of non-compliance of the policy and/or allegation of misconduct, you should work with your institution’s legal counsel, risk management, and office of institutional
equity to ensure compliance with your institution’s Grievance Policy and/or Sexual Misconduct Policy. Given that institutional policies and state laws vary, examples are not included for this section.

Key components for consideration:

  • Timely investigations of suspected inappropriate behavior should be conducted by an impartial external office (e.g., Title IX, Office of Equity and Inclusion, campus law enforcement, medical ethics review board).

  • Results of external investigations should be reviewed by institutional general counsel, outside counsel hired specifically for the investigation, or a human resources team and should be shared with the governing body of the organization for corrective action as indicated.

  • If an investigation of a licensed health professional reveals sexual misconduct, the college or university should consider their responsibility of informing the health professional’s licensing board of the misconduct.

ACHA Sensitive Exams Task Force

These guidelines were developed by ACHA’s Sensitive Exams Task Force. A special thanks to the task force members: Susan Ernst, MD, and Mary Landry, MD (Task Force Chairs); Robert Ernst, MD; Stephanie Hanenberg, MSN, FNP-C, FACHA; Ann Laros, MD; and Kim Webb, MEd, LPC.