This chapter is concerned with the issue of documentation, which was an area of concern in the stage one interviews, as discussed in Chapter Four. Examining the issues of culpability, documentation, confidentiality, and the medical record is important, as it is through the written patient record that medical complaints become integrated in medical discourse, through research and the acknowledgement of clinical practice. There are a number of issues which relate both directly and indirectly to the use of medical records, including the use of medical records in training; legal discourses; as an ‘event’ itself within the medical encounter; as representative of the hierarchy which exists between different healthcare professionals; naming; recording; and the appropriation of the sick role. Examining the medical record is important, as it has been suggested (Berg, 1996) that the medical record, rather than merely representing the medical encounter, is an event in itself. This implies that the medical record, like the appropriation of the sick role, exerts a social control function, situated between the medical encounter and medical discourse. Considering that medical records document the medical encounter and the processes, diagnosis, and treatments utilised within it, it is frequently used in research to ascertain the health needs and provision of local communities and society more generally. The medical record functions, therefore, to legitimise the entrance of knowledge into medical discourse, and as a result is important in the evaluation of the health interaction which occurs between women who experience domestic violence and healthcare professionals.

The medical record as a legal document

The most formidable function of the medical record is in legal discourse. Due to the position of medical discourse in society, such records are considered valuable as accurate representations of individuals’ experiences of health and well-being, particularly in relation to crimes against the person. First, considering the assertion that the medical record is an event in itself rather than a representation of the medical encounter (Berg, 1996), this could be questioned. Second, problems exist in identifying specific aspects of medicalised problems such as domestic violence, as documented throughout this book. When discussing the use of the medical record, particularly in relation to domestic violencerelated injuries, the assertions by the stage two participants demonstrated how they considered the legal implications of their ‘aid memoir’ to be of central importance.