Ms. U worked as a nurse practitioner in the emergency department (ED) of a rural hospital. Because the hospital was located in an agricultural area, in addition to the illnesses and accident-related injuries seen typically in the ED, Ms. U also saw many farm-related injuries—including trauma sustained from animals or equipment.

Ms. U was on duty one afternoon when a mother showed up with her 9-year-old son. The child’s face was clearly bruised, and he was limping when he walked. His mother, Mrs. E, looked drawn and haggard, and the little boy acted skittish and uneasy. Ms. U picked up the patient’s chart and led Mrs. E and her son to an examination area.

Ms. U did her best to make the boy feel comfortable as she propped him up on the examination table. She gently asked what had happened, and the boy looked nervously at his mother. Mrs. E’s son then told Ms. U that a cow had kicked him. Ms. U noted this in the chart and smiled sympathetically, but there was something about the boy’s anxiety that raised her antennae. She asked him to get undressed so she could examine him further.

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In addition to the bruises on his face, Mrs. E’s son had extensive bruising on his back, buttocks, and legs. Ms. U began to seethe, but she took a deep breath to steady herself and then slowly wrote a detailed description in the chart of all the child’s bruises. When Ms. U was done, she excused herself and approached a colleague.

“Would you tell Mrs. E to step out and complete some paperwork so I can speak to her son alone?” she asked. “I have a feeling he was beaten and can’t talk about it in front of her.”

When Ms. U was finally alone with Mrs. E’s son, she made small talk to help the boy relax and then eased in and asked again what had happened. Mrs. E’s son looked panicked and said, “I told you already, the cow kicked me.”

“That’s not really what happened, is it?” Ms. U asked gently. “I can see from your bruises that it wasn’t a cow. It’s okay. You can talk to me.”

After a bit of prodding, the boy admitted that his stepfather had beaten him—and that this wasn’t the first time. “My mom saw it happen, but she didn’t do anything, she didn’t help me. She told me to blame it on the cow.” The boy began to cry. Ms. U consoled him and then wrote a lengthy note in the file detailing the conversation.

Ms. U told Dr. S, her supervising physician, about her findings. In apprising Dr. S of the situation, Ms. U related her initial encounter with the mother and her son, the boy’s subsequent physical examination findings, and what the boy told her in private. Dr. S examined the child himself and agreed that signs of abuse were present. Dr. S explained that a report needed to be filed with Child Protective Services immediately.

Mrs. E’s son was subsequently removed from his mother and stepfather’s house. The boy was placed in foster care while the district attorney decided whether to press charges against the stepfather. An assistant district attorney came to speak with Ms. U about the case. The attorney also took a copy of the child’s medical records. Within the next week, criminal charges were filed against the stepfather.

The stepfather pleaded not guilty and the case went to trial. Ms. U was called as a witness for the prosecution.

Ms. U testified as to what she’d seen and related her conversation with Mrs. E’s son. The prosecutor introduced the boy’s medical records—with Ms. U’s detailed notes—into evidence, despite objections by the defense attorney. During closing arguments, the defense attorney contended that Mrs. E’s son was an unreliable witness on the basis that the boy had originally told one story (about being kicked by a cow) and later changed it. The defense attorney also asserted that Ms. U’s testimony was hearsay; it was based only on what Ms. U had heard from the boy and not from what she had actually seen. Lastly, the defense argued that Ms. U’s notes in the medical record should be inadmissible, as they represented merely her opinion.

The judge ultimately allowed the boy’s medical record to be admitted into evidence, and the jury was allowed to use it to come to a decision. Within an hour, the jury convicted the stepfather of felony child abuse.

Legal background

The legal definition of hearsay evidence is “a statement made out of court and not under oath, which is offered as proof that what is stated is true.” Another way of saying this is that hearsay is testimony of what a witness heard someone else say. It is often regarded as unreliable and not subject to cross-examination (since the attorney cannot actually speak to the person who made the original statement). Another reason why hearsay is not usually admitted as evidence in criminal cases is the right of the accused to confront his or her accuser. Because hearsay is secondhand information, the defendant does not get to question the person who made the original statement. In this case, the defense attorney tried to argue that what Ms. U wrote in her notes and what she testified to hearing Mrs. E’s son say was hearsay since it was being offered as evidence that the stepfather had beaten the boy. In cases such as this, a prosecutor may try to proceed without the testimony of a young child to prevent any further emotional trauma.

There are numerous exceptions to the hearsay rule in the United States—including an exception for records made in the regular course of business. Documentation of the boy’s physical condition and statements made during the examination that were noted in the chart were therefore deemed admissible.

Protecting yourself

There are countless reasons why clinical documentation is essential. Usually, documentation serves as a means of protection. Clinical notes indicate what medication was prescribed, whether a patient was referred to a specialist, and what follow-up was advised. Without Ms. U’s careful notation of the child’s physical condition, her suspicions that his injuries were not consistent with being kicked by a cow, and the boy’s admission that he was beaten, there might not have been a case against the stepfather. In essence, it was not just the fact that Ms. U noticed the abuse but that she properly documented it that helped procure a conviction. Her careful and extensive documentation essentially protected the future of a little boy whose abuse might have gone undetected and unpunished. n

Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.