Table 2.

Strategies for performing a trauma-informed physical examination

Usual care approach	SAMHSA’s six principles	Trauma-informed care approach
• Not taking the time to enhance physical and psychological safety in the room even with interruptions (i.e., not obtaining curtains for hallway beds) • Leaving the patient exposed when not clinically necessary. For example, exposing both sides of the chest when only one is being examined • Using phrases that may have been a part of a traumatic experience (i.e., “relax” or “calm down”) • Using language that may have a sexual connotation such as asking patients to complete an action “for me” such as “open your mouth for me”	Safety	• If a patient is in a waiting room or hallway bed, take extra time to move them to an exam room, or ensure curtains can be moved to their location • Throughout the exam, drape or cover the patient to maintain comfort and privacy. Use appropriate draping techniques to systematically expose and re-drape areas as they are being examined • Use language that is neutral, objective, and professional to direct the patients’ actions. “Push the right arm forward” or “Could you please lift the left breast”
• Beginning the exam without a patient understanding what is being examined or why. This is especially important during trauma evaluations as patients are often scared and disoriented • Leaving the exam room without updating the patient on pertinent findings from the physical examination • Using words such as “good” or “nice” to describe findings. “Everything looks good. I will be back in a few minutes to check in”	Trust & transparency	• Outline the overall steps of the exam and how long it should take • If the patient would like narration, narrate to the patient what you are examining and why. Recap the major findings at the end of the physical examination using neutral language such as “healthy” to describe findings
• Either letting a visitor stay in the examination room when inappropriate or removing a trusted support person without checking in with the patient	Peer support	• Determine with the patient if it would be appropriate to have their visitor in the room during the exam or if they would like a chaperone. Often, patients may not feel comfortable if this individual is already in the room, so it is best to ask when the patient is alone
• Performing actions for patients without consent such as untying a gown before beginning the examination • Asking politely for the patient to perform actions without eliciting the patient’s perspective. “Just breathe for me, okay?” • Asking patients if they are comfortable, but not giving an option to improve their level of comfort	Collaboration & mutuality	• Consider ways to incorporate patients into the exam. For example, have the patient guide the stethoscope under the breast when auscultating • Check in to see if anything can be done to make the patient more comfortable, i.e., “Would you feel more comfortable sitting up or resting back?”
• Asking if the patient is ready to start the exam without exploring if they have any questions or concerns • Not creating the space for a patient to speak up for when they are uncomfortable or if they have any concerns	Empowerment, voice, & choice	• Invite questions or concerns the patient may have before beginning the exam. “Do you have any questions or concerns I can address about this exam?” • Ask for permission before touching the patient, especially in sensitive areas such as the neck, chest, breast, genitals, or rectum
• Not adjusting to meet a patient’s cultural needs (e.g., having a female provider perform a pelvic exam) • Not using a translator or having someone who is not a certified translator explain the purpose of the exam or narrate the exam	Cultural, gender, historical issues	• If an all-male team, find a chaperone for a female patient who is presenting for assault or intimate partner violence. Can be addressed by asking, “Would you be comfortable with a male physician performing the exam today?” • Consider how culture may influence the perceived appropriateness of a provider’s touch • Utilize translator services when appropriate to ensure informed consent for the examination