Medical records are often used as evidence in domestic violence cases. Clear, concise, and factual documentation can help establish that abuse has occurred. Medical professionals may not be aware that subtle differences in the way they document cases of domestic abuse can affect the usefulness of their records if there is a hearing. For example, “excited utterances” or “spontaneous exclamations” should be carefully documented because they have exceptional credibility due to their proximity to the event and because they are not likely to be premeditated. The victim or the victim’s attorney can use a medical record to obtain a restraining order; qualify for special status or exemptions in public housing, welfare, health and life insurance, victim compensation, and immigration relief related to domestic violence; and to resolve landlord-tenant disputes (Isaac & Enos, 2001).
According to a number of studies, many medical records are not sufficiently documented to provide adequate legal evidence of domestic violence. A study of 184 visits for medical care in which an injury or other evidence of abuse was noted revealed major shortcomings in the records:
- For the 93 instances of an injury, the records contained only 1 photograph. There was no mention in any records of photographs filed elsewhere (eg, with the police).
- A body map documenting the injury was included in only 3 of the 93 instances. Drawings of the injuries appeared in 8 of the 93 instances.
- in one-third of the patients’ visits in which abuse or injury was noted, doctors’ and nurses’ handwriting was illegible in key portions of the records. Criteria for considering a patient’s words an “excited utterance” were met in only 28 of the more than 800 statements evaluated (3.4%). Most frequently missing was a description of the patient’s demeanor, and often the patient was not clearly identified as the source of the information. (Isaac & Enos, 2001)
Medical records could be more useful to domestic violence victims in legal proceedings if some minor changes were made in documentation. Clinicians can do the following:
- Take photographs of injuries known or suspected to have resulted from domestic violence.
- Write legibly. Computers can also help overcome the common problem of illegible handwriting.
- Set off the patient’s own words in quotation marks or use such phrases as “patient states” or “patient reports” to indicate that the information recorded reflects the patient’s words. To write “patient was kicked in abdomen” obscures the identity of the speaker.
- Avoid such phrases as “patient claims” or “patient alleges,” which imply doubt about the patient’s reliability. If the clinician’s observations conflict with the patient’s statements, the clinician should record the reason for the difference.
- Describe the person who hurt the patient by using quotation marks to set off the statement. The clinician would write, for example: The patient stated, “My boyfriend kicked and punched me.”
- Avoid summarizing a patient’s report of abuse in conclusive terms. If such language as “patient is a battered woman,” “assault and battery,” or “rape” lacks sufficient accompanying factual information, it is not admissible.
- Do not place the term domestic violence or abbreviations such as “DV” or “IPV” in the diagnosis section of the medical record. Such terms do not convey factual information and are not medical terminology. Whether domestic violence has occurred is determined by the court.
- Describe the patient’s demeanor, indicating, for example, whether she is crying or shaking or seems angry, agitated, upset, calm, or happy. Even if the patient’s demeanor belies the evidence of abuse, the clinician’s observations of that demeanor should be recorded.
- Record the time of day the patient is examined and, if possible, indicate how much time has elapsed since the abuse occurred. For example, the clinician might write, “Patient states that early this morning his boyfriend hit him” (Isaac & Enos, 2001).