A doctor faces possible legal action for carrying out an intimate examination of a naked patient without offering her a chaperone.
In a decision released on Monday, Health and Disability Commissioner Anthony Hill says the male doctor touched the woman's genitals during the examination and showed a lack of respect.
Mr Hill says the doctor breached patient rights in several areas.
The woman, a visitor to New Zealand, saw the unnamed doctor at an after-hours clinic in mid-2011 with a suspected urinary tract infection.
She told Mr Hill that she never complained of vaginal pain, but the doctor examined her upper and lower body, including her groin, breasts and back without gloves.
She was fully naked for part of this time, felt uncomfortable and phoned later to complain, taping the call.
Mr Hill says the doctor breached patient rights, including altering his clinical records to support his version of events.
"There was a lack of respect for her dignity and for her privacy. There was a lack of communication, there was a problem with the examination itself and then there was the issue with the notes being amended in the way in which they were."
The commissioner asked the doctor to apologise and says this has not happened.
The doctor has been referred for possible follow-up legal action and a competency review.