Updated FAQ and policy for Use of Chaperones
18 Jun 2023Final reminder: New policy starts July 1
By: Salem Hospital and West Valley Hospital Medical Executive Committees
Common Ground articles were sent March 12, April 23and June 4, about updates to Salem Health’s Use of Chaperones policy to align with the Oregon Medical Board rule change, which begins Saturday, July 1.
Credentialed providers were advised to seek clarity from their respective section chiefs or the Medical Staff Office to help prepare for Medical Chaperone Rule OAR 847-010-0130. The Physician Leadership Council comprised of 30 clinical section chiefs continue to review feedback and questions from credentialed providers which includes ongoing review of the policy as we prepare for implementation.
An important update to the policy:
Frequently asked questions:
Can a patient’s medical chaperone preference be stored in the patient’s record and not offered each time?
The SHHC policy was updated to include standards regarding documentation of the presence or refusal of a chaperone. The policy was also updated to include standards regarding a one-time offer of a chaperone in the SHHC inpatient and outpatient settings. Below is a revised excerpt from the SHHC policy:
“The presence or refusal of a chaperone must be documented by the credentialed provider in the clinical notes to include the chaperone name, role and credentials (if applicable). If a chaperone is declined, documentation must include date of declination and reason, if known. If an examination is performed in the inpatient setting, a medical chaperone may be offered one time, per provider, per hospital stay and must be documented in the patient’s chart noting the patient’s decision and that the presence or refusal of a chaperone applies to the length of stay for that particular credentialed provider. If an examination is performed in the outpatient and ambulatory care setting, then a one-time offer may be made per visit and must be documented in the patient’s chart. In all situations where a patient requests a chaperone, each credentialed provider must document for each examination the chaperone name, role and credentials (if applicable).”
Please refer to the Oregon Medical Board’s FAQ #7 (below) regarding this specific question, which resulted in further revisions to the policy.
Next steps
- Please read the most up-to-date FAQ from the OMB (below).
- Please ensure you are familiar with the most up-to-date SHHC policy on Use of Chaperones (below). The policy was recently revised to include expanded language on a one-time offer, as outlined above, and updated to provide further clarity on the provider’s documentation requirements, based on feedback from the medical staff.
Questions?
Contact your clinical section chief or Kelly Aebi with the Medical Staff Office at 503-814-3889 or Kelly.Aebi@salemhealth.org.
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