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.

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, verbal offer before examinations, documentation requirements (offered, accepted/declined, chaperone name)
6. Who Can Act as a Chaperone — trained staff members only, family members are NOT substitutes, 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, 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), students and observers (explicit consent, may withdraw at any time)
13. Training — chaperone training at induction, annual refresher, register of trained chaperones
14. Reporting Concerns — raising concerns with Practice Principal, AHPRA mandatory notification, protection for reporters
15. Related Policies — cross-references to Privacy, Informed Consent, Complaints, Clinical Risk, Training
16. Review History — version control and approval

Editable placeholder fields

• {{practice_name}}, {{abn}}, {{practice_address}}, {{phone}}, {{email}}
• {{practice_principal_name}}, {{review_date}}, {{next_review_date}}

RACGP accreditation requirement

Criterion C2.2 requires that the practice has a policy for the presence of a third party during a consultation. Surveyors will typically check:

• A documented chaperone policy exists
• Patients are informed about chaperone availability (signage, information materials)
• Staff can describe when and how chaperones are offered
• Clinical records document chaperone offers and decisions for sensitive examinations
• Staff who act as chaperones have received appropriate training

Key references

• RACGP Standards for General Practices (5th Edition) — Criterion C2.2
• Medical Board of Australia — Good Medical Practice: A Code of Conduct for Doctors — guidance on professional boundaries and intimate examinations
• RACGP Fact Sheet: Chaperones — practical guidance for general practice

How to customise this template

1. Download and fill in all {{placeholder}} fields
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 staff 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 all practitioners on the documentation requirements — chaperone offer, acceptance/declination, and chaperone name must be recorded

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. The key requirement is that the offer is made and documented. Any patient may request a chaperone for any examination, regardless of type.

Can a family member act as a chaperone?

A family member or friend brought by the patient is a support person, not a formal chaperone. They may be present if the patient wishes, but they do not replace a trained staff member acting as a chaperone. A formal chaperone is a practice staff member who has received chaperone training.

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 and role of the chaperone if one was present. 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 Criterion C2.2. Surveyors will check for a documented policy, patient information materials, staff training, and evidence of documentation in clinical records.