Good medical records- the difference can be vital

One of the most common family law subpoenas to issue is to a person’s GP, specialist or a hospital where they were treated. At times,subpoenaed medical evidence can make a critical difference. Here are some examples: – a party who said that she had been but was no longer a drinker, had a reference in… Read More »Custom Single Post Header

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Good medical records- the difference can be vital

One of the most common family law subpoenas to issue is to a person’s GP, specialist or a hospital where they were treated.

At times,subpoenaed medical evidence can make a critical difference. Here are some examples:

– a party who said that she had been but was no longer a drinker, had a reference in her GP’s notes “alcohol”
– a party who said that she had been assaulted by her former partner by his kicking her in the back when she was pregnant, resulting in her attending a GP and telling him that she had been bruised in a game of soccer, had a reference in the GP’s notes about bruising
– a party who denied that he had any difficulties with drugs, and that he was generally in good health, had a very long history of being prescribed major pain relief by his GP
– a party who said that he had never been violent to his former partner, had a history of hospital entries involving serious alcohol and drug use and violence to his former partners, and having been restrained by two hospital guards for attempting to drink a bottle of Hibitane.

Some time ago I stumbled on this site, which is a media release from Harvard School of Public Health about research by Nancy Isaac saying the kinds of things one would hope would be in medical records when domestic violence is alleged.

I particularly liked their cheat sheet:

-Take photographs of injuries.

-Write legibly. Illegible notes are useless as legal documentation.

-Use quotation marks or the phrases “patient states” or “patient reports” to indicate that the information came directly from the patient.

-Avoid words that imply doubt about the patient’s reliability, i.e. “patient alleges.”

-Do not use legal terms such as “alleged perpetrator.” Legal terms are defined in detail by statute and case law. By using legal terms, providers may convey an unintended meaning.

-Name the person the patient says hurt her by using quotation marks and recording the identifying information. This prevents the abuser from obscuring his responsibility by accusing the victim of having multiple partners.

-Avoid using conclusory terms such as “patient is a battered woman.” Conclusions without sufficient accompanying factual information are inadmissible.

-Placing the term “domestic violence” or abbreviations such as “DV” in the diagnosis fields of medical records is of no benefit to the patient in legal contexts.

-Include words that describe a patient’s demeanor, such as: “crying, angry, agitated.”

-Record the time of day and some indication of how much time has passed since the incident.

Things to Read, Watch & Listen

Forced Marriage

On November 1st 2023, Accredited Family Law Specialist and Page Provan Director Stephen Page presented a paper at the Brisbane Zonta Club about forced marriage. I acknowledge the Jagera and Turrbal peoples, on whose lands we meet today, their elders, past, present and emerging. Ruqia Hidari was aged 21 and living in Victoria, when, according to police,… Read More »Forced Marriage

ACT Government Surrogacy Bill

The ACT Government has today introduced a bill to amend the ACT’s surrogacy laws. The proposed changes are more incremental than fundamental. They include allowing a single person to undertake surrogacy, for the surrogate to be single if needed, a requirement for legal advice and counselling beforehand, a written agreement being required, that traditional surrogacy is… Read More »ACT Government Surrogacy Bill

Planning to resolve: ADR in ART

ADR can help resolve disputes in ART cases. ADR is not limited to mediation and arbitration. Other types of informal dispute resolution can resolve disputes. When assisted reproductive treatment cases go off the rails, they can have the next level of bitterness and volatility. There can be a keen sense of betrayal when things don’t… Read More »Planning to resolve: ADR in ART