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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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7. Chaperones & Personal Privacy
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A medical practitioner who is a lover of wisdom is equal to a god.
~ Hippocrates
Privacy Betrayal
The Importance of Chaperones and Personal Privacy in Medical Care
Detective Johnson sat at her desk, poring over the file of the recent murder case. It had been a particularly gruesome one, with the victim found in their home, strangled to death. As she read through the report, she realized that the victim was a patient of Dr. Smith, a local family practitioner. She decided to pay him a visit to gather more information.
Upon arriving at the clinic, Detective Johnson introduced herself to Dr. Smith and explained her reason for being there. Dr. Smith seemed visibly shaken upon hearing the news of his patient’s death and willingly answered her questions. He confirmed that he had seen the victim the day before her death for a routine physical examination.
Detective Johnson asked about the use of a chaperone during the examination. Dr. Smith explained that he always used a chaperone when performing sensitive exams, such as a pelvic exam, to ensure patient comfort and respect for their dignity. He also confirmed that he had used a chaperone during the victim’s exam. The chaperone, a nurse named Sarah, had been working with Dr. Smith for years.
However, when asked about the privacy measures taken during the exam, Dr. Smith seemed hesitant. Detective Johnson pressed further, stating that she had reason to believe that the victim’s privacy was violated during the examination. After a few moments of silence, Dr. Smith admitted that he had failed to provide the victim with a private area to undress and that he had not appropriately covered the patient during the exam.
Feeling uneasy, Detective Johnson asked Dr. Smith about any discussions of confidential patient information that may have taken place during the exam. He admitted that he had discussed the victim’s medical history with Nurse Sarah, the chaperone present, and that he had not offered the patient a private conversation to discuss any sensitive information.
Detective Johnson decided to interview Nurse Sarah next. As she questioned her, she noticed that Sarah seemed nervous and avoided eye contact. When asked about her relationship with the victim, Sarah hesitated but eventually admitted to having a long-standing grudge against her. She confessed to overhearing the victim’s confidential information during the exam and using that knowledge to confront and ultimately strangle the victim in a fit of rage.
Detective Johnson left the clinic with a clear understanding of the events that led to the victim’s murder. Nurse Sarah was arrested and charged with the murder. Dr. Smith was also held accountable for violating HIPAA confidentiality and patient privacy laws, leading to the loss of his medical license.
As Detective Johnson walked away from the clinic, she was reminded of the importance of chaperones and personal privacy in medical care delivery. She couldn’t help but feel that if Dr. Smith had followed these crucial components of the medical culture, the victim might still be alive today.
Abstract
The importance of using chaperones in medical examinations to aid comfort and respect for the patient’s dignity should not be underestimated. Patients should be given the choice to have a family member or non-family member chaperone present and all institutional and legal requirements for chaperone use should be disclosed. Privacy should be provided for undressing and the examination should not violate the patient’s dignity. Confidential patient information should not be discussed in the presence of the chaperone or family members, unless there is explicit patient permission to do so, to avoid HIPAA confidentiality violations. Communication between the patient and practitioner must allow for a private conversation to discuss confidential information freely. Chaperones and privacy are crucial for medical care and HIPAA confidentiality requirements must be respected.
**
Think
[7:1] Chaperones can significantly aid in the comfort of both the patient and the medical practitioner under various circumstances and conditions. This respect for the patient’s dignity, through the use of a chaperone, is in line with the professional moral duty of beneficence (do good).
Assess
Patient: 1) Autonomy
[7:2] Clear communication should be made to the patient that they may choose to have a family member chaperone or a non-family member chaperone present during their examination. Any institutional or legal requirements for the use of a chaperone should also be disclosed.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[7:3] Based on the professional principle of beneficence (do good), private facilities should be provided to the patient for undressing and putting on a medical gown. Appropriate covering and drapery should also be used during the medical examination. At no time should private areas of the patient’s body ever be exposed to family members or the chaperone as that could be a violation of the patient dignity, could seriously disrupt the family social structure, and as such could be a violation of the professional principle of nonmaleficence (do no harm).
[7:4] The American College of Physicians (ACP) states:
The location and degree of privacy should be appropriate for the examination being performed, with chaperone services as an option.
Public Policy: 4) Justice
[7:5] All discussions of confidential patient information, such as inquiries into the patient’s protected health information (PHI), medical history, and other sensitive information, must be kept to a minimum while the chaperone or family member(s) are present. Failure to do so could result in HIPAA confidentiality violations and a violation of the principle of nonmaleficence (do no harm). The Health Insurance Portability and Accountability Act (HIPAA) is a federal statute with fines of up to $250,000 and a jail term of up to 5 years.
[7:6] Communication between the patient and the practitioner is highly privileged, a central component of the patient-practitioner relationship, and is legally protected. Therefore, the practitioner must always provide the patient with the opportunity for a private conversation where all confidential protected health information (PHI) can be freely discussed. Such practices align with all four bioethical principles: patient autonomy (informed consent), practitioner beneficence (do good), practitioner nonmaleficence (do no harm), and public justice (be fair).
Conclude
[7:7] Chaperones and personal privacy are essential parts of the medical culture and medical care delivery. Not violating any of the HIPAA confidentiality requirements and recognizing the importance of the opportunity for the patient to be able to have a private conversation with the practitioner, without any family members or chaperone being present, is imperative so that the patient can have a free and open discussion about their personal and medical history with the practitioner.
[7:8] In summary, chaperones and personal privacy are integral components of medical care delivery. Adhering to HIPAA confidentiality requirements and providing opportunities for private conversations between patients and practitioners without the presence of chaperones or family members is critical for fostering open and honest discussions about personal and medical history. Respecting patient autonomy and upholding the principles of beneficence, nonmaleficence, and justice are essential for maintaining trust and ensuring the best possible patient care.
(See also: 8. Confidentiality and 31. Medical Records)
**
7. Review Questions
1. Chaperones can significantly aid in the comfort of both the patient and the practitioner under various circumstances and conditions. This respect for the patient’s dignity, through the use of a chaperone, is in line with the professional moral duty of beneficence (do good).
2. Since a chaperone is a medical professional, it is permissible for the chaperone to see the patient’s exposed private areas assuring that no impropriety occurs.
3. A chaperone is legally authorized to hear discussion regarding the patient’s protected health information.
4. The practitioner is protected from HIPAA violations when using chaperones.
**
CORRECT! 🙂
[7:1] Chaperones can significantly aid in the comfort of both the patient and the practitioner under various circumstances and conditions. This respect for the patient’s dignity, through the use of a chaperone, is in line with the professional moral duty of beneficence (do good).
Wrong 😕
[7:1] Chaperones can significantly aid in the comfort of both the patient and the practitioner under various circumstances and conditions. This respect for the patient’s dignity, through the use of a chaperone, is in line with the professional moral duty of beneficence (do good).
CORRECT! 🙂
[7:3] Based on the professional principle of beneficence (do good), private facilities should be provided to the patient for undressing and putting on a medical gown. Appropriate covering and drapery should also be used during the medical examination. At no time should private areas of the patient’s body ever be exposed to family members or the chaperone as that could be a violation of the patient dignity, could seriously disrupt the family social structure, and as such could be a violation of the professional principle of nonmaleficence (do no harm).
Wrong 😕
[7:3] Based on the professional principle of beneficence (do good), private facilities should be provided to the patient for undressing and putting on a medical gown. Appropriate covering and drapery should also be used during the medical examination. At no time should private areas of the patient’s body ever be exposed to family members or the chaperone as that could be a violation of the patient dignity, could seriously disrupt the family social structure, and as such could be a violation of the professional principle of nonmaleficence (do no harm).
CORRECT! 🙂
[7:6] Communication between the patient and practitioner is highly privileged, a central component of the patient-practitioner relationship, and legally protected. Therefore, the practitioner must always provide the patient with the opportunity for a private conversation where all confidential protected health information (PHI) can be freely discussed. Such practices align with all four bioethical principles: patient autonomy (informed consent), practitioner beneficence (do good), practitioner nonmaleficence (do no harm), and public justice (be fair).
Wrong 😕
[7:6] Communication between the patient and practitioner is highly privileged, a central component of the patient-practitioner relationship, and legally protected. Therefore, the practitioner must always provide the patient with the opportunity for a private conversation where all confidential protected health information (PHI) can be freely discussed. Such practices align with all four bioethical principles: patient autonomy (informed consent), practitioner beneficence (do good), practitioner nonmaleficence (do no harm), and public justice (be fair).
CORRECT! 🙂
[7:5] All discussions of confidential patient information, such as inquiries into the patient’s protected health information (PHI), medical history, and other sensitive information, must be kept to a minimum while the chaperone and family member(s) are present. Failure to do so could result in HIPAA confidentiality violation (justice) and a violation of the principle of nonmaleficence (do no harm). The Health Insurance Portability and Accountability Act (HIPAA) is a federal statute with fines of up to $250,000 and a jail term of up to 5 years.
Wrong 😕
[7:5] All discussions of confidential patient information, such as inquiries into the patient’s protected health information (PHI), medical history, and other sensitive information, must be kept to a minimum while the chaperone and family member(s) are present. Failure to do so could result in HIPAA confidentiality violation (justice) and a violation of the principle of nonmaleficence (do no harm). The Health Insurance Portability and Accountability Act (HIPAA) is a federal statute with fines of up to $250,000 and a jail term of up to 5 years.
7. Clinical Vignettes
1. Ms. Kaitlyn Clark, a 23-year-old sales person, who identifies as non-binary, is coming in for a routine physical examination. They have expressed concerns about privacy and modesty during the examination. As a practitioner, it is important to ensure the comfort and dignity of all patients during medical procedures. Which of the following is the most appropriate action for the practitioner to take in this situation?
2. Ms. Kimberly Chen, a 21-year-old college student has come in for a medical examination and requested that a chaperone be present during the procedure. The practitioner follows the professional principle of beneficence (do good) by providing private facilities for the patient to undress and put on a medical gown and using appropriate covering and drapery during the examination. However, during the examination, the practitioner realizes that the chaperone has scooted their seat to a vantage point at allows them to see the patient's private areas. What is the most appropriate course of action for the practitioner to take to maintain the patient's dignity, social structure, and abide by the professional principle of nonmaleficence (do no harm)?
3. Ms. Carmen Hernandez, a 32-year-old human resources professional comes to clinic for a routine check-up in a facility that has an open examination room design with only thin curtains separating patients. During the examination, the practitioner notices that the patient seems uncomfortable discussing certain medical information. The practitioner recognizes the importance of protecting patient privacy and the privileged communication between the patient and practitioner. What is the best course of action for the practitioner to take?
4. Ms. Zoe Lee, a 33-year-old retail worker, comes to the clinic for a routine check-up accompanied by their spouse. During the examination, the practitioner must discuss confidential medical information with the patient, including sensitive information about their medical history and current health status. What is the best course for the practitioner to avoid HIPAA confidentiality violations and protect patient privacy?
5. Mr. Jeremiah Adams, a 28-year-old architect is undergoing a medical examination with a practitioner. During the examination, the patient's chaperone or family member(s) are present in the room. Which of the following is the most appropriate way for the practitioner to handle confidential patient information during the examination?
CORRECT! 🙂
Explanation: Offering the patient the option of having a chaperone present during the examination is the most appropriate action for the practitioner to take in this situation. [7:1] It is important for practitioners to respect the patient's privacy and modesty concerns, and to provide options that allow the patient to feel comfortable and respected during the examination. [7:2] Requiring the patient to have a chaperone present during the examination may not be necessary or may further contribute to the patient's discomfort, and may not respect the patient's concerns for privacy and modesty. [7:1] The use of a chaperone is in line with the professional moral duty of beneficence (do good) and can significantly aid in the comfort of both the patient and the medical practitioner. [7:2]
Wrong 😕
Explanation: Offering the patient the option of having a chaperone present during the examination is the most appropriate action for the practitioner to take in this situation. [7:1] It is important for practitioners to respect the patient's privacy and modesty concerns, and to provide options that allow the patient to feel comfortable and respected during the examination. [7:2] Requiring the patient to have a chaperone present during the examination may not be necessary or may further contribute to the patient's discomfort, and may not respect the patient's concerns for privacy and modesty. [7:1] The use of a chaperone is in line with the professional moral duty of beneficence (do good) and can significantly aid in the comfort of both the patient and the medical practitioner. [7:2]
Wrong 😕
Explanation: The most appropriate course of action for the practitioner to take to maintain the patient's dignity, social structure, and abide by the professional principle of nonmaleficence is to stop the examination and provide additional privacy measures. [7:1] The practitioner must ensure that the patient's privacy and dignity are protected, and any perceived violation of these must be addressed immediately. [7:3] It is essential to create a safe and secure environment for the patient and to respect their autonomy and preferences. [7:2] Therefore, the practitioner should explain the situation to the patient and offer them the option to continue the examination with a different chaperone, or without a chaperone, as per their preference. [7:2] The importance of using chaperones in medical examinations to aid comfort and respect for the patient’s dignity should not be underestimated. [7:1] The practitioner should also take necessary steps to address the issue with the chaperone to prevent similar incidents in the future. [7:1]
CORRECT! 🙂
Explanation: The most appropriate course of action for the practitioner to take to maintain the patient's dignity, social structure, and abide by the professional principle of nonmaleficence is to stop the examination and provide additional privacy measures. [7:1] The practitioner must ensure that the patient's privacy and dignity are protected, and any perceived violation of these must be addressed immediately. [7:3] It is essential to create a safe and secure environment for the patient and to respect their autonomy and preferences. [7:2] Therefore, the practitioner should explain the situation to the patient and offer them the option to continue the examination with a different chaperone, or without a chaperone, as per their preference. [7:2] The importance of using chaperones in medical examinations to aid comfort and respect for the patient’s dignity should not be underestimated. [7:1] The practitioner should also take necessary steps to address the issue with the chaperone to prevent similar incidents in the future. [7:1]
Wrong 😕
Explanation: The professional principles of beneficence and nonmaleficence prioritize the patient's privacy and comfort during the examination. [7:1] Insisting on discussing the medical information in the open examination room could be a violation of the patient's privacy and could make them feel uncomfortable, which would be against the professional principle of nonmaleficence. [7:3] Refusing to discuss the medical information privately or offering to discuss it over the phone could also be problematic because they would not provide the patient with adequate privacy, which is necessary for the patient-practitioner relationship. [7:6] Thus, offering to discuss the medical information in a private room is the most appropriate action for the practitioner to take in this situation. [7:6]
CORRECT! 🙂
Explanation: The professional principles of beneficence and nonmaleficence prioritize the patient's privacy and comfort during the examination. [7:1] Insisting on discussing the medical information in the open examination room could be a violation of the patient's privacy and could make them feel uncomfortable, which would be against the professional principle of nonmaleficence. [7:3] Refusing to discuss the medical information privately or offering to discuss it over the phone could also be problematic because they would not provide the patient with adequate privacy, which is necessary for the patient-practitioner relationship. [7:6] Thus, offering to discuss the medical information in a private room is the most appropriate action for the practitioner to take in this situation. [7:6]
Wrong 😕
Explanation: As a part of maintaining patient privacy and confidentiality, practitioners should ensure that only necessary people have access to the patient's confidential medical information [7:5]. In this case, the patient's spouse is not required to be present during the discussion of sensitive medical information, and the practitioner should ask them to leave the examination room [7:2]. By doing so, the practitioner would protect the patient's privacy, maintain confidentiality, and abide by the professional principle of nonmaleficence [7:3]. Discontinuing the examination or refusing to discuss the information altogether would not necessarily address the issue at hand, whereas discussing the information in front of the spouse would violate the patient's privacy and confidentiality [7:5].
CORRECT! 🙂
Explanation: As a part of maintaining patient privacy and confidentiality, practitioners should ensure that only necessary people have access to the patient's confidential medical information [7:5]. In this case, the patient's spouse is not required to be present during the discussion of sensitive medical information, and the practitioner should ask them to leave the examination room [7:2]. By doing so, the practitioner would protect the patient's privacy, maintain confidentiality, and abide by the professional principle of nonmaleficence [7:3]. Discontinuing the examination or refusing to discuss the information altogether would not necessarily address the issue at hand, whereas discussing the information in front of the spouse would violate the patient's privacy and confidentiality [7:5].
CORRECT! 🙂
Explanation: The practitioner should respect the patient's privacy and maintain confidentiality of protected health information (PHI) during the examination [7:1]. Although the chaperone or family member(s) may be present in the examination room, the practitioner should still maintain confidentiality of the patient's PHI during the examination [7:5]. By doing so, the practitioner is upholding the principle of beneficence by respecting the patient's dignity, promoting trust in the patient-practitioner relationship [7:1], and following professional and legal standards for protecting patient privacy [7:5].
Wrong 😕
Explanation: The practitioner should respect the patient's privacy and maintain confidentiality of protected health information (PHI) during the examination [7:1]. Although the chaperone or family member(s) may be present in the examination room, the practitioner should still maintain confidentiality of the patient's PHI during the examination [7:5]. By doing so, the practitioner is upholding the principle of beneficence by respecting the patient's dignity, promoting trust in the patient-practitioner relationship [7:1], and following professional and legal standards for protecting patient privacy [7:5].
**
7. Cases: 7a, 7b
Instructions
1. Read Prompt, 2. Think, Assess, & Conclude (TAC), then 3. Select an answer that mirrors the TAC conclusion.
Note: After success, select each of the wrong answers to understand why each of them is wrong.
7a
The patient agrees to have a chaperone present during a well-patient visit. During the check-up, it appears that there is an indication that the patient may have contracted a sexually transmitted disease, and personal questions as to sexual activity need to be discussed.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
7b
The patient agrees to have a spouse act as a chaperone during a well-patient visit. During the check-up, the practitioner notices some old and new bruises on the patient. When the practitioner starts to enquire about the bruises, the spouse interjects about how clumsy the patient is, with no response from the patient.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
Wrong 😕
A. Since the patient chose to have a chaperone, it follows that all private health information (PHI) can also be disclosed to the chaperone and patient.
Choosing to have a chaperone is different than choosing to disclose personal health information (PHI). Caution must be used when discussing sensitive information when a chaperone is present. Best practices would be to see the patient in private when discussing PHI.
Wrong 😕
B. The practitioner should candidly ask the patient and chaperon if it is permissible to talk about the patient’s sexual activity.
The practitioner should discuss private health information in private with the patient. Asking the chaperon about such communications, is already disclosing too much information.
CORRECT! 🙂
THINK (Question)
Should the practitioner have a private conversation with just the patient?
ASSESS
- • Patient Autonomy (informed consent)
Patient’s have the right to choose to have a chaperons present. - • Practitioner Beneficence (do good) &Nonmaleficence (do no harm)
Patient privacy are essential parts of the medical culture and medical care delivery. Recognizing the importance of the opportunity for the patient to be able to have a private conversation with the practitioner, without any family members or chaperon present, is imperative so that the patient can have a free and open discussion about their personal and medical history. - • Public-Policy Justice (be fair)
HIPAA confidentiality of the patient’s PHI must not be violated.
CONCLUDE
The practitioner should have a private conversation with just the patient.
Wrong 😕
D. If the chaperone is a family member then a third party chaperone should be substituted before asking questions about the patient’s sexual activity.
Caution must be used when discussing personal health information (PHI) regardless of who the chaperone is. Best practices would be to see the patient in private when discussing any type of PHI.
Wrong 😕
A. The practitioner should report the suspected abuse to Adult Protective Services regardless of patient informed consent.
To report the suspected abuse without the patient’s informed consent would be a HIPAA confidentiality violation. Therefore the practitioner should e the patient to report, offer to report on behalf of the patient, and make sure the patient has a safe place to retreat.
CORRECT! 🙂
THINK (Question)
Under suspicion of patient abuse by a chaperone, should the practitioner report?
ASSESS
- • Patient Autonomy (informed consent)
The patient has the right to have a private conversation with the practitioner and to trust that their practitioner will keep their confidential health information private. - • Practitioner Beneficence (do good) &Nonmaleficence (do no harm)
The practitioner should allow the patient to have a private conversation without family members or chaperons. If the patient is a victim of abuse, then the practitioner should encourage the patient to report, offer to report the suspected abuse on behalf of the patient, and ensure that the patient has a safe place to retreat. - • Public-Policy Justice (be fair)
The practitioner must get informed consent from the patient before reporting suspected abuse.
CONCLUDE
The practitioner should have a private conversation with the patient, encourage the patient to report, offer to report the suspected abuse on behalf of the patient, and ensure that the patient has a safe place to retreat.
Wrong 😕
C. The practitioner should have a private conversation with the chaperon to determine if the chaperon is the source of the patient's abuse.
Regardless of the practitioner’s evidence, reporting the suspected abuse without the patient’s informed consent would be a HIPAA confidentiality violation. Therefore the practitioner’s focus should be on encouraging the patient to report, offer to report on behalf of the patient, and ensure that the patient has a safe place to retreat.
Wrong 😕
D. The practitioner should report this incident to the local police and have the abusing chaperon immediately arrested before any more harm befalls the victim.
To report the suspected abuse without the patient’s informed consent would be a HIPAA confidentiality violation. Therefore, the practitioner should encourage the patient to report, offers to report on behalf of the patient, and ensures that the patient has a safe place to retreat.
