Chaperone Policy Template for Australian General Practices

What's in this template?

This chaperone policy is designed for Australian general practices preparing for RACGP accreditation under the Standards for General Practices (5th Edition). It maps directly to Criterion C2.2, Presence of a third party during a consultation. In the 6th edition, published on 26 August 2026, the same subject sits under criterion PP4.B (informed consent for third-party presence). Accreditation assessments still use the 5th edition.

The template covers 16 sections:

1. Purpose: protecting patient dignity and providing practitioner support during examinations
2. Scope: all practitioners, all clinical examinations, all patients including children and adolescents
3. Definitions: chaperone, sensitive examination, third party
4. When a Chaperone Should Be Offered: sensitive examinations (breast, genital, rectal), significant undressing, vulnerable patients, gender-discordant consultations, patient or practitioner request
5. Offering and Documenting Chaperone Availability: waiting area signage, new patient information, prior consent at booking or reception to any third party the practice arranges (rechecked at the start of the consultation), verbal offer before examinations, documentation requirements (consent, offered, accepted/declined, chaperone name or initials and role)
6. Who Can Act as a Chaperone: trained clinical team members (not reception or the practice manager), a patient's own adult chaperone with the risks explained and the person's details recorded, gender preference where possible
7. Responsibilities of the Chaperone: emotional support, positioning, independent witness, intervention, confidentiality; what a chaperone should NOT do
8. When a Patient Declines a Chaperone: respect the decision, document, proceed or defer at practitioner's discretion
9. When No Chaperone Is Available: reschedule, the patient's own adult chaperone, clinical urgency exception with documentation, referral consideration
10. Children and Adolescents: parent/guardian presence for young children, adolescent privacy and Gillick competence, mandatory reporting obligations
11. Practitioner-Initiated Chaperone: practitioner's right to request, explaining the reason, right to decline proceeding without chaperone
12. Other Third Parties During Consultations: support persons (confirm consent privately), third parties arranged by the practice (interpreters, registrars, observers, students: consent at booking or reception, never first asked in the consulting room, role or initials recorded, guardian or advocate consent where the patient cannot consent)
13. Training: chaperone training at induction, annual refresher, register of trained chaperones
14. Reporting Concerns: raising concerns with Practice Principal, Ahpra mandatory notification (including sexual misconduct), protection for reporters
15. Related Policies: cross-references to Privacy, Informed Consent, Complaints, Clinical Risk, Training
16. Review History: version control and approval

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RACGP accreditation requirement

Criterion C2.2 of the 5th edition requires the practice to obtain and document the patient's prior consent whenever it introduces a third party (chaperone, student, observer, registrar or interpreter) to a consultation. Consent is sought when the appointment is made or at reception, never for the first time in the consulting room. A written policy is recommended, not mandatory. Surveyors will typically check:

• Health records show the patient's prior consent to any third party the practice arranged
• A documented chaperone policy exists
• Patients are informed about chaperone availability (signage, information materials)
• Staff can describe when and how chaperones are offered and how consent is sought
• Clinical records document chaperone offers and decisions for sensitive examinations
• Staff who act as chaperones have received appropriate training

In the 6th edition, the same requirement sits under criterion PP4.B, which asks that the practice "facilitates the documentation of the patient's consent to the presence of a third party arranged by the practice".

Key references

• RACGP Standards for General Practices (5th Edition): Criterion C2.2
• RACGP Standards for General Practices (6th Edition): Criterion PP4.B
• Medical Board of Australia, Good Medical Practice: A Code of Conduct for Doctors: guidance on professional boundaries and intimate examinations
• Medical Board of Australia, Guidelines: Sexual boundaries in the doctor-patient relationship: section 7.1, use of observers
• RACGP fact sheet: The use of chaperones and observers in general practice: practical guidance for general practice

How to customise this template

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2. Create signage for the waiting area and consultation rooms informing patients of chaperone availability
3. Include chaperone information in your new patient registration pack
4. Identify and train clinical team members who will act as chaperones. Maintain a register of trained chaperones
5. Update your clinical record templates to include a chaperone documentation field for sensitive examinations
6. Brief reception and practitioners: reception asks for consent to any third party the practice arranges when the appointment is made or on arrival; practitioners recheck that consent at the start of the consultation and record it, along with the chaperone offer, the patient's decision, and the chaperone's name or initials and role

Frequently asked questions

Is a chaperone required for every examination?

No. A chaperone should be offered for all sensitive examinations (breast, genital, rectal, or examinations requiring significant undressing). The patient may accept or decline, and the offer and decision are documented. For accreditation, the key requirement is prior consent: when the practice arranges a third party, including a chaperone, the patient is asked before the consultation (when booking or at reception), the consent is rechecked at the start of the consultation, and it is recorded in the health record. Any patient may request a chaperone for any examination, regardless of type.

Can a family member act as a chaperone?

Yes, if the patient chooses. The practice offers a trained member of its clinical team by default, but a patient may choose their own chaperone or observer, such as a spouse, partner, parent, other family member, guardian or carer, who is at least 18 years of age. The patient is told that choosing a friend or family member carries risks, including breaches of confidentiality and embarrassment, and the GP records the person's name and qualifications in the health record. The practitioner may still ask for a practice observer as well.

What should be documented in the clinical record?

For sensitive examinations, document: (1) that a chaperone was offered, (2) whether the patient accepted or declined, and (3) the name or initials and role of the chaperone if one was present. For any third party the practice arranged (chaperone, student, observer, registrar or interpreter), also record the patient's consent and the third party's role or initials. This documentation protects both the patient and the practitioner.

What about telehealth consultations?

Chaperone considerations are primarily relevant to in-person physical examinations. During telehealth consultations, patients are in their own environment. If a telehealth consultation involves the patient undressing for a visual examination, the practitioner should discuss privacy and comfort with the patient and document accordingly.

Can I use this for AGPAL or QPA accreditation?

Yes. Both accrediting bodies assess against RACGP 5th edition Criterion C2.2. In the 6th edition the same subject sits under criterion PP4.B, but assessments still use the 5th edition. Surveyors will check for a documented policy, patient information materials, staff training, and evidence in clinical records, including the patient's prior consent to any third party the practice arranged.