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Chaperone policy aligns with OMB rule change

04 Jun 2023

Starts July 1, get clarity from your section chief

By: Salem Hospital and West Valley Hospital Medical Executive Committees

Common Ground articles on March 12 and April 23 shared updates to Salem Health’s Use of Chaperones policy to align with the Oregon Medical Board rule change starting Saturday, July 1. 

Here’s an update:

Credentialed providers were advised to seek clarity from their respective section chiefs or the Medical Staff Office to help prepare for the upcoming 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.

Frequently Asked Questions:

Who is a Credentialed Provider under the Use of Chaperones policy?

While the SHHC policy changes were prompted by the Oregon Medical Board, which apply to OMB licensees, the MEC and policy stakeholders included Nurse Practitioners and Certified Nurse Midwives to the policy for continuity at all Salem Health Hospitals and Clinics. Under this policy a Credentialed Provider is considered an MD, DO, DPM, DDS, DMD, PA, NP and CNM credentialed and privileged at SHHC.

By SHHC policy, who is required to document the presence or refusal of a chaperone in the chart note?

It is the Credentialed Provider’s responsibility to document the presence or refusal of a chaperone. The clinical notes should include the chaperone name, role and credentials (if applicable). If a chaperone is declined, documentation should include date of declination and reason if known.

An Epic smart phrase was created to streamline documentation. It’s titled .chapadult and a pediatric smart phrase is currently being developed.   

Is a chaperone required for procedures?

Per the OMB FAQ #25, the rule is for examinations and not procedures; however, in any situation a patient is entitled to request a chaperone be present should they want one. Beginning July 1, 2023, the SHHC policy states the Credentialed Provider must offer a trained chaperone to be physically present for:

  • Genital and rectal examinations regardless of gender; and
  • Breast examinations for patients who identify as female.

You can find a revised FAQ sheet from the OMB with detailed information here.

Still have questions? Please contact your clinical section chief or Kelly Aebi with the Medical Staff Office at 503-814-3889 or