Medical Records as Legal Evidence of Domestic Violence

• NCJ Number: 184530
• Author(s): Nancy E. Issac Sc.D.; Pualani Enos J.D.
• Date Published: 2000
• Length: 97 pages
• Grant Number(s): 97-WT-VX-0008
• Agencies: NIJ-Sponsored
• Publication Type: Report (Study/Research)

Annotation

This study sought to describe, from a legal perspective, how domestic violence was documented in the medical charts of abused women, based on a review of 96 medical charts of 86 abused women covering 772 visits to two Boston area hospitals.

Abstract

For 184 of the 772 visits (24 percent), detailed information was abstracted on the medical records in which there was an indication of domestic violence, an injury of some type, or both. Findings revealed that legal and medical communities hold many misperceptions about each other's roles in responding to domestic violence, and that many barriers to collaboration are based on these misperceptions and false assumptions. Some legal advocates did not use regularly use medical records in civil contexts or to their full potential in criminal contexts. Reasons for not using medical records included difficulty and expense in obtaining them, illegibility, incompleteness or inaccuracy, and the possibility that the information would be more harmful than helpful. 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. Among medical visits that contained some indication of abuse or injury, one-third of notes from doctors or nurses contained vital information that was illegible. Nonetheless, many health care providers recorded significant details regarding injuries and health conditions in abused women's charts. Photographs were almost never present in the medical charts, and the medical records did not mention photographs stored in other locations, such as with the local police. The authors identify changes in documentation practices that may improve the usefulness of abused women's medical records in legal contexts and that may help health care providers to work more effectively in support of abused patients. Data abstraction tools used in the study are appended. 37 references and 10 tables