708.5Medical Diagnosis/Treatment [Rule 803(4)]

The Basic Rule

Rule 803(4) – Statements for Purposes of Medical Diagnosis or Treatment

G.S. 8C-803(4). The rationale for this hearsay exception is that the declarant has a built-in motivation to be truthful and accurate when providing information for the purpose of obtaining medical care, which makes the statements inherently trustworthy. See G.S. 8C-803(4), Official Commentary (statements about a patient’s present condition and past medical history, offered for the purpose of obtaining a diagnosis or treatment, are allowed “in view of the patient’s strong motivation to be truthful”).

Requirements for Admissibility

“Rule 803(4) requires a two-part inquiry: (1) whether the declarant's statements were made for purposes of medical diagnosis or treatment; and (2) whether the declarant's statements were reasonably pertinent to diagnosis or treatment.” State v. Hinnant, 351 N.C. 277 (2000).

Purpose and Intent

To be admissible, the declarant must have understood that obtaining a medical diagnosis or treatment was the purpose behind making the statement, and the declarant must have made the statement with that intent. See, e.g., Matter of J.M., 255 N.C. App. 483 (2017) (mother’s statements to doctors during a check-up and subsequent emergency visit that father was rough with child and had punched him in the stomach were admissible); State v. Burgess, 181 N.C. App. 27 (2007) (videotaped interviews between children and nurses were for the purpose of diagnosis and treatment). The court considers “all objective circumstances of record surrounding declarant's statements in determining whether he or she possessed the requisite intent under Rule 803(4).” State v. Hinnant, 351 N.C. 277 (2000); see also State v. Carter, 153 N.C. App. 756 (2002) (court determined declarant’s intent based on testimony from doctors and nurses who spoke with the child).

A statement made to non-medical personnel (e.g., a family member, teacher, or counselor) may still qualify under this hearsay exception, as long as the surrounding circumstances establish that the statement was made for diagnosis or treatment purposes. See G.S. 8C-803(4), Official Commentary (“[T]he statement need not have been made to a physician. Statements to hospital attendants, ambulance drivers, or even members of the family might be included”); State v. Corbett & Martens, 376 N.C. 799 (2021) (hearsay statements made by children during intake procedures and forensic interview at a child advocacy center were erroneously excluded, should have been admitted under this exception); State v. Crumbley, 135 N.C. App. 59 (1999) (“Statements made to an individual other than a medical doctor may constitute statements made for the purpose of medical diagnosis or treatment.”); State v. Figured, 116 N.C. App. 1 (1994) (child's statements to a social worker regarding sexual abuse were admissible under Rule 803(4) since the statements were made for the purpose of medical diagnosis or treatment); State v. Smith, 315 N.C. 76 (1985) (child’s statement to grandmother describing bleeding and pain were made for medical purpose).

A statement may be admitted under this exception even if there was a “dual” purpose to the statement: e.g., treatment or diagnosis and investigation or trial preparation. See State v. Isenberg, 148 N.C. App. 29 (2001) (exception applied where statement had dual purpose, both medical evaluation and preparation for trial); State v. Lewis, 172 N.C. App. 97 (2005) (child declarants’ statements were made for medical purpose, despite potential later use at trial: relevant inquiry “seeks to determine the child's purpose in making the statement, not the interviewer's purpose in conducting the interview”). 

However, if the primary (or only) purpose behind conducting the exam or making the statement was not related to obtaining a medical diagnosis or treatment, then Rule 803(4) does not apply. See, e.g., State v. Lowery, 219 N.C. App. 151 (2012) (where the primary objective was to develop evidence to support a mental illness defense, defendant’s statements to doctor were not admissible under this exception); State v. Harris, 338 N.C. 211 (1994) (“Since defendant's statements to Dr. Brown were made in preparation for trial, they were not admissible under the hearsay exception contained in Rule 803(4).”); State v. Stafford, 317 N.C. 568 (1986) (examination and interview done solely for purpose of preparing to present “rape trauma syndrome” at trial not admissible under this exception).

Reasonably Pertinent

The second requirement for a statement to be admissible under this hearsay exception is that it be “reasonably pertinent” to obtaining a diagnosis or treatment. See G.S. 8C-803(4), Official Commentary (“Thus a patient's statement that he was struck by an automobile would qualify but not his statement that the car was driven through a red light.”). See, e.g., State v. Lowery, 219 N.C. App. 151 (2012) (excluding defendant’s statement to doctor that he only confessed in order to avoid the death penalty since it was not relevant to medical evaluation); State v. Norman, 196 N.C. App. 779 (2009) ("Because Defendant failed to affirmatively establish that J.G.'s mother made her statements to Taylor for the purpose of diagnosis or treatment of J.G., her statements fail the first prong of the Hinnant test."); State v. Gattis, 166 N.C. App. 1 (2004) (excluding portion of defendant’s statement to doctors that the gun was discharged accidentally; statement was only relevant to fault, not treatment of the gunshot wound); State v. Waddell, 351 N.C. 413 (2000) ("The record also lacks any evidence that there was a medical treatment motivation on the part of the child declarant or that Rockwell-Flick or anyone else explained to the child the medical purpose of the interview or the importance of truthful answers."); State v. Aguallo, 318 N.C. 590 (1986) (statement identifying assailant was not pertinent to medical treatment).

Similarly, a statement made after the declarant has already received medical care is unlikely to qualify under this exception, because the statement is no longer reasonably pertinent to obtaining a diagnosis or treatment. See State v. Hinnant, 351 N.C. 277 (2000); State v. Smith, 315 N.C. 76 (1985); State v. Watts, 141 N.C. App. 104 (2000).

Children as Declarants

One of the most common uses of the Rule 803(4) hearsay exception is to introduce statements made during a medical examination by a child who was the victim of sexual abuse or assault. As mentioned in Section B above, courts tend to take a broader view of the exception when the declarant is a child. Thus, courts have held that statements from a child to a non-medical person may nevertheless be made for the purpose of seeking medical care, and statements identifying the perpetrator may be pertinent to determining appropriate medical treatment such as ordering therapy or removing the child from the home. See, e.g., State v. Norman, 196 N.C. App. 779 (2009) (“young children cannot independently seek medical attention. Therefore, a child's statements to a non-medical person, such as a therapist, social worker, or even members of the family may be admissible under Rule 803(4) when the statements meet the two-pronged test outlined in Hinnant”); State v. Youngs, 141 N.C. App. 220 (2000) (“[w]here children are examined by physicians for diagnosis and treatment of alleged sexual abuse, details of the offense, including the identity of the offender, provided by the child during such examination are generally admissible at trial”), quoting State v. Rogers, 109 N.C. App. 491 (1993).

For a more detailed discussion of Rule 803(4) and other evidentiary issues in the context of child witness cases, see Jessica Smith, “Child Victims and the Medical Diagnosis and Treatment Hearsay Exception,” N.C. Criminal Law Blog, April 30, 2012. See also Jessica Smith, “Evidence Issues in Criminal Cases Involving Child Victims and Child Witnesses,” N.C Superior Court Judges’ Benchbook, December 2008.