Medical Records as Legal Evidence of Domestic Violence, Summary Report

• NCJ Number: 184528
• Author(s): Nancy E. Issac Sc.D.; Pualani Enos J.D.
• Date Published: May 2000
• Length: 12 pages
• Grant Number(s): 97-WT-VX-0008
• Agencies: NIJ-Sponsored
• Publication Type: Report (Study/Research)

Annotation

This project brought together a uniquely experienced team of researchers, medical personnel (including social workers), attorneys, and judges to consider what forms of potentially available medical documentation would be most useful in substantiating abuse of women in a variety of legal contexts.

Abstract

The study reviewed 96 medical charts belonging to 86 abused women who made 772 visits to two Boston area hospitals. The visits involved health care received in recent years; 70 percent of the visits were made in 1997 or later, and only 15 percent were made before 1995. Each of the 772 visits was reviewed to identify any indication of domestic violence that would call for more detailed data abstraction. In total, 184 of the 772 visits (24 percent) were abstracted. Many different aspects of medical documentation by doctors, nurses, social workers, psychiatrists, and emergency medical technicians were examined. Findings showed it was difficult to obtain medical records in a timely fashion. Among health care visits, only 1 of the 93 visits involving an injury contained a photograph. Although photographs and body maps were rare, injuries were otherwise described in detail. One-third of notes from doctors or nurses, however, contained vital information that was illegible. Negative statements about patient appearance, manner, or motives were present in less than 1 percent of the medical records. Many health care providers were confused about whether, how, and why to record information about domestic violence in medical charts. In an effort to be neutral regarding abuse situations, some health care providers used language that was likely to harm an abused woman's legal case. The study identified some relatively minor changes in documentation practices that may improve the usefulness of abused women's medical records in legal contexts. 2 tables