Chapter 3 – Health Care Operations

3.1.23 Presence of a Chaperone in Health Care Examinations

• Policy
  California Correctional Health Care Services (CCHCS) shall ensure a Chaperone is present for a health care examination as required by law or policy.

• Procedure

  • Requirements for Presence of a Chaperone

    • A Chaperone shall be present:

      • During health care examinations involving genitalia, rectum, or breast, except for mammography.

      • When requested by the patient or health care provider.

    • A Chaperone shall not be required in an emergency when waiting may jeopardize patient safety.

    • Dental encounter requirements shall be governed pursuant to Health Care Department Operations Manual (HCDOM), Section 3.3.5.13, Access to Dental Care.

  • Professional Expectations of a Chaperone
    The Chaperone shall:

    • Be health care staff;

    • Be present during the portion of the encounter for which the Chaperone’s presence is required or requested;

    • Serve as an impartial observer; and

    • Report any concerns regarding potential staff misconduct in accordance with the Department Operations Manual, Chapter 3, Article 14, Internal Affairs Investigations, Sections 31140.1-31140.45.

  • Documentation Requirements
    The health care provider performing the exam shall document the presence of a Chaperone in accordance with HCDOM, Section 1.4.2.4, Medical Provider Documentation Expectations.

• References

  • California Code of Regulations, Title 15, Division 3, Chapter 2, Article 1, Section 3999.303, Scheduling and Access to Care

  • Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.7, Institution Patient Safety Program

  • Health Care Department Operations Manual, Chapter 1, Article 4.2, Section 1.4.2.4, Medical Provider Documentation Expectations

  • Health Care Department Operations Manual, Chapter 3, Article 3.5, Section 3.3.5.13, Access to Dental Care

  • Department Operations Manual, Chapter 3, Article 14, Sections 31140.1 – 311140.45

  • American College Health Association, ACHA Guidelines Best Practices for Sensitive Exams. October 2019

  • American Medical Association, AMA Code of Medical Ethics, Use of Chaperones

• Policy Control
  Executive Sponsor: Deputy Director, Medical Services
  Effective: 10/12/2026