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July 30, 2001
Nov 11, 2001 rev
December 16, 2001 rev
February 8, 2002 rev

CSME Standards & Guidelines Committee (CSME-S&GC) - Drafting Sub-committee Interim Report

I Proposal for a Guideline entitled:

The Presence of Additional Parties during a Clinical Physical Assessment

An Independent Medical Evaluation is a complex process in which data from direct clinical interaction with the evaluee and from documentation review are synthesized by the evaluator into conclusions pertinent to the issues for which the referral was made.

The Clinical Assessment component typically consists of an Interview and a Physical Examination.

It is the position of the CSME that in certain circumstances, in addition to the evaluator and evaluee there may be one or more parties whose presence is either essential or desirable to facilitate the process. It is also our position that other than for essential parties, the final decision as to which parties will be present (as active participant or in passive support) rests entirely with the medical evaluator.

The CSME recommends that, where feasible, during the entire Physical Examination the evaluee and evaluator should be accompanied by a trained chaperone. This must be prefaced by an introduction and explanation to the evaluee of the reasons for chaperoning pertaining to both the evaluee and evaluator. It is also recommended that upon completion of the examination, the chaperone should independently record relevant information about the event including duration; remarkable incidents; and any expressions of concern by the evaluee about the assessment.

The CSME considers essential the presence of a parent or legal guardian whenever a minor undergoes a clinical assessment, involving interview and/or physical examination.

The CSME considers essential the presence during interview and physical examination of a responsible, first order relative or current caregiver, whenever the evaluee suffers from substantial cognitive impairment arising from developmental handicap, severe head injury, degenerative neurologic disease or psychiatric disorder.

The CSME recommends that each evaluator develop or adopt a protocol to standardize policy for inviting another party into the interview and/or physical examination, when the evaluee does not fall into the above two categories, taking into account the following considerations:

1. any evaluee who has previously suffered sexual abuse at the hands of a physician, and whose concerns have been brought to proper authorities in a formal complaint, should be regarded as requiring additional supportive reassurance through the presence during the physical examination of another party mutually acceptable to evaluator and evaluee. If this additional party is not a professional chaperone, then in addition a professional chaperone must be present for the evaluator's benefit.
    
2. any evaluee who remains apprehensive about the impending physical examination, despite preliminary explanation of the process and further discussion with the professional staff, should be offered the option of not proceeding at that time. If the evaluee elects to proceed, the evaluator should exercise discretion by ensuring the presence of a professional chaperone. The evaluator should also consider permitting a first order relative to be present during the physical examination.

Finally, the CSME takes the position that clinical assessments must take place in an atmosphere conducive to achieving all of the requisite clinical goals, free from interruption, distraction, threatening or disruptive behaviour. The presence of an additional party has the potential of significantly detracting from the quality of the assessment. In order to prevent this, and entirely at the discretion of the evaluator, any additional party may be asked to sit behind the line of sight of the evaluee and also to not respond in any fashion (exclamation, sigh, gesture, expression etc) to questions posed to or answers given by the evaluee unless or until specifically invited to participate by the evaluator. If, for any reason, the evaluator finds that the continuing presence of the additional party is hindering the achievement of the assessment goals, then at the sole discretion of the evaluator the additional party may be asked to leave. If that party fails to comply, and/or the evaluee is not prepared to continue without that party, then the clinical assessment session should be terminated immediately.