Sexually Transmitted Infections (STI) in Adolescents — Chaperone Considerations, Documentation — Clinical Pathway: Emergency and Primary Care

Sexually Transmitted Infections (STI) in Adolescents Clinical Pathway — Emergency Department and Primary Care

Chaperone Considerations, Documentation

Offer patients and parents/guardians the option of having a chaperone during sensitive parts of the exam. A parent, family member, friend, or clinical staff can serve as a chaperone.

Use these EHR smartphrases to document that a chaperone was offered for sensitive examinations.

.chaperone
  • Select:
    • Patient,
    • Guardian,
    • Staff,
    • No one
  • A chaperone was offered to the patient for the sensitive parts of this exam, including breast and/or GU exams.
  • The chaperone offer was {not accepted} accepted by the patient and *** was present for selected portions of this exam.
Permission to perform a Sensitive Area Exam
.SensitiveAreaExamConsent
  • Select:
    • Patient,
    • Parent,
    • Physician,
    • Nurse,
    • Chaperone,
    • Other
  • “I have explained to patient/caregiver the medical indications for a Sensitive Area exam (involving the inspection or palpitation of the anorectal or genital areas or the breast).
  • Patient/caregiver expressed understanding of reason to perform the Sensitive Area exam.
  • Verbal permission was obtained from patient/caregiver prior to performing the Sensitive Area exam.
  • Patient tolerated exam well.
  • People present during exam.
Denied Permission to perform a Sensitive Area exam
.SensitiveAreaExamNoConsent
  • Select:
    • Patient,
    • Caregiver,
    • Physician,
    • Nurse,
    • Social Work,
    • Chaperone,
    • Other
  • “I have explained to patient/caregiver the medical indications for a Sensitive Area exam (involving the inspection or palpitation of the anorectal or genital areas or the breast).
  • Patient/caregiver expressed understanding of reason to perform the Sensitive Area exam.
  • Patient/caregiver declined permission to proceed with the Sensitive Area exam at this time.
  • People present in room during discussion.