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Documentation — DFSRH MCQ

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EasyDocumentationDFSRH

A 31-year-old woman attends a sexual and reproductive health clinic for removal of an intrauterine device because she wishes to conceive. Her female partner remains in the room at the patient’s request. Before the speculum examination, the clinician explains the examination and obtains consent. A trained clinic chaperone is actively offered, but the patient declines, stating that her partner provides sufficient support. The clinician has no professional or safety concern about proceeding without a formal chaperone, and the examination and removal are uncomplicated. Which is the most appropriate documentation of the examination?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Record the indication and consent, the active chaperone offer and decline, the partner’s name and relationship, and the decision to proceed.

Explanation lettering: C = shown as A · A = shown as B · B = shown as C

A partner may provide emotional support but does not replace the requirement to offer a formal chaperone for an intimate examination. A patient with capacity may decline that offer. Where the clinician judges that proceeding would not compromise professional standards or patient safety, the examination may proceed with appropriate safeguards and documentation. The record should identify the indication and examination, consent, the active offer of a chaperone and the patient’s decision, any decision to proceed or defer, and the name and role or relationship of other people present. Therefore, C provides the complete and auditable entry. A is incorrect because the partner attended as a support person and should not be retrospectively designated as the formal chaperone. B correctly records the declined offer but omits information required when another person is present. D is incorrect because the presence of a partner does not remove the requirement to offer a formal chaperone. E would be appropriate if the clinician considered that proceeding without a chaperone would compromise safety or professional standards; those concerns are explicitly absent here, so mandatory deferral would not respect the patient’s informed decision.

Reference: Service Standards for Record Keeping in Sexual and Reproductive Healthcare Services (2019) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-service-standards-for-record-keeping-2019.pdf Improving chaperoning practice in the NHS: key principles and guidance (5 December 2025) — https://www.england.nhs.uk/long-read/improving-chaperoning-practice-in-the-nhs-key-principles-and-guidance/