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NCJ Number: NCJ 184528     Find in a Library
Title: Medical Records as Legal Evidence of Domestic Violence, Summary Report
  Document URL: PDF 
Author(s): Nancy E. Issac Sc.D. ; Pualani Enos J.D.
Date Published: 05/2000
Page Count: 12
  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
Main Term(s): Victims of violence
Index Term(s): Evidence identification and analysis ; Criminal investigation ; Medical research ; Medical evaluation ; Domestic assault ; Abused women ; Female victims ; NIJ final report ; NIJ grant-related documents
Sponsoring Agency: National Institute of Justice (NIJ)
US Department of Justice
Office of Justice Programs
United States of America
Grant Number: 97-WT-VX-0008
Sale Source: NCJRS Photocopy Services
Box 6000
Rockville, MD 20849-6000
United States of America

Northeastern University School of Law
Domestic Violence Institute
Boston, MA 02115
United States of America
Type: Report (Study/Research)
Country: United States of America
Language: English
Note: See NCJ-184530 for the full report.
  To cite this abstract, use the following link:

* A link to the full-text document is provided whenever possible. For documents not available online, a link to the publisher's web site is provided.