Hearsay and circumstances of its admissibility - Statements ...

Learning Outcomes

This article explains the hearsay exception for statements made for purposes of medical diagnosis or treatment under Federal Rule of Evidence 803(4), including:

• Identifying when a statement falls within Rule 803(4) by analyzing exam fact patterns for purpose, subject matter, and reasonable relevance to diagnosis or treatment
• Distinguishing admissible statements describing symptoms, medical history, inception, or general cause of injury from inadmissible statements that merely assign legal fault or blame
• Determining whose statements may qualify, including patients, parents, caregivers, and bystanders, and to whom such statements may be directed for diagnostic or treatment purposes
• Analyzing third‑party and child‑declarant statements in abuse or domestic‑violence scenarios where the identity of the perpetrator may itself be medically relevant
• Applying the exception to both physical and psychological conditions, including trauma‑focused treatment and mental‑health evaluations frequently appearing in MBE hypotheticals
• Evaluating statements made to non‑physicians—such as EMTs, nurses, counselors, or litigation‑related experts—and determining when a genuine medical‑diagnosis purpose is present
• Resolving hearsay‑within‑hearsay issues in medical records by pairing the business‑records exception with Rule 803(4) and spotting related Confrontation Clause problems on criminal questions

MBE Syllabus

For the MBE, you are required to understand hearsay and its exceptions, including the medical diagnosis or treatment exception, with a focus on the following syllabus points:

• The definition of hearsay and the general rule of exclusion
• The exception for statements made for purposes of medical diagnosis or treatment (FRE 803(4))
• The requirements for admissibility: purpose/motive, subject matter, and relevance to diagnosis or treatment
• Who may make the statement (patient or third party) and who may receive it
• The scope of statements covered (symptoms, medical history, cause and source of injury)
• The distinction between statements of fault and statements of cause
• Reliability concerns and how courts evaluate such statements in civil and criminal cases

Test Your Knowledge

Attempt these questions before reading this article. If you find some difficult or cannot remember the answers, remember to look more closely at that area during your revision.

1. Which of the following statements is most likely admissible under the hearsay exception for medical diagnosis or treatment?
   1. “The driver who hit me was texting and going 20 miles over the limit.”
   2. “My leg hurts and I cannot move it.”
   3. “I think my neighbor dislikes me and wants my job.”
   4. “I want to sue the hospital for malpractice.”
2. A mother brings her injured child to the emergency room and tells the doctor, “He fell off his bike and hit his head on the curb.” The child is too young to speak. Is the mother’s statement admissible for the truth of the matter asserted under the medical diagnosis/treatment exception?
   1. Yes, if the statement was made to obtain medical care for the child.
   2. No, because the mother is not the patient.
   3. No, because it is hearsay within hearsay.
   4. Yes, but only if the child later confirms the statement in court.
3. Under the medical diagnosis/treatment exception, which of the following is generally NOT admissible?
   1. The patient’s statement about the location of pain.
   2. The patient’s statement about when the pain started.
   3. The patient’s statement identifying the cause of injury.
   4. The patient’s statement assigning legal blame for the injury.

Introduction

Hearsay is generally inadmissible unless an exception applies. One important and frequently tested exception is for statements made for purposes of medical diagnosis or treatment. The rationale is practical: people seeking medical help have a strong motive to tell the truth so that they can be diagnosed and treated effectively. That motive makes their statements sufficiently reliable to be admitted even though they are made out of court.

Key Term: Hearsay
An out‑of‑court statement offered to prove the truth of the matter asserted.

Key Term: Declarant
The person who made the out‑of‑court statement that is being offered in evidence.

The medical diagnosis or treatment exception appears in Federal Rule of Evidence 803(4). Like all Rule 803 exceptions, it applies whether or not the declarant is available to testify, and in both civil and criminal cases.

Key Term: Medical Diagnosis or Treatment Exception
A hearsay exception allowing a declarant’s statement made for, and reasonably relevant to, medical diagnosis or treatment to be admitted for its truth.

The Medical Diagnosis or Treatment Exception (FRE 803(4))

Under Rule 803(4), the following are admissible:

• Statements made for purposes of medical diagnosis or treatment, and
• That describe medical history; past or present symptoms or sensations; their inception; or their general cause, insofar as reasonably relevant to diagnosis or treatment.

Notice several key features that often drive MBE questions:

• The exception focuses on the purpose/motive of the declarant when speaking
• It focuses on the subject matter of the statement (symptoms, history, cause/source)
• Admissibility does not depend on whether the declarant later testifies
• The statement may be used for its truth, not merely to show that it was said

Key Term: Reasonably Relevant
For this exception, the statement must be helpful or reasonably related to the medical professional’s diagnosis or treatment of the patient.

Requirements for Admissibility

For a statement to qualify under the medical diagnosis or treatment exception, three core requirements must be met on the exam:

1. Proper Purpose (Motive)
   The statement must be made for the purpose of obtaining medical diagnosis or treatment (including mental health treatment). Courts assess this objectively: did the declarant reasonably believe that the statement would help receive proper medical care?

   • Statements made during an ER visit, a visit to a primary‑care doctor, a mental health evaluation, or to an on‑scene paramedic usually satisfy this element.
   • Statements made purely to build a lawsuit, with no genuine medical purpose, usually do not.

2. Proper Subject Matter
   The statement must describe one or more of the following:

   • Present symptoms: “My chest feels tight.”
   • Past symptoms: “I had a headache all day yesterday.”
   • Medical history: “I have diabetes and high blood pressure.”
   • Inception or general cause: “I fell from a ladder,” “I was hit by a car.”

   The content must be the kind of information doctors and other medical professionals use to diagnose and treat.

3. Reasonable Relevance to Diagnosis or Treatment
   The information must be reasonably helpful to diagnosis or treatment in the particular context.

   • A description of the mechanism of injury (e.g., “I twisted my knee while running”) is relevant because it helps determine what structures may be damaged.
   • A description of legal blame (e.g., “the store was negligent”) is not medically helpful and is not covered by this exception.

If these three elements are satisfied, the statement can be admitted for its truth under Rule 803(4).

Who May Make the Statement

The declarant is often the patient, but Rule 803(4 is not limited to the patient’s own statements. Third‑party statements may qualify when they are made for the patient’s benefit and meet the other requirements.

Common third‑party declarants on the MBE include:

• A parent describing a young child’s symptoms or how the injury occurred
• A spouse or caregiver describing an unconscious or confused patient’s history
• A teacher bringing a child to the nurse and describing what the child said or did

The key is still purpose and relevance to treatment:

• If the third party is giving information so that the patient can be treated, and
• The information is reasonably relevant to diagnosis or treatment,

then the statement can fall within the exception, even though the declarant is not the patient.

Statements of Cause vs. Statements of Fault

The MBE often tests the line between medically relevant “cause” and inadmissible “fault.”

Key Term: Statement of Cause
A statement explaining how an injury or condition occurred (e.g., “I fell down the stairs” or “I was hit by a car”), offered to help diagnose or treat the condition.

Key Term: Statement of Fault
A statement assigning blame or legal responsibility (e.g., “my landlord forgot to fix the stairs,” “the driver was drunk”), usually not admissible under this exception.

• Statements of cause/source are admissible if reasonably related to diagnosis or treatment:

  • “I was hit in the head with a baseball bat.”
  • “I inhaled fumes at work and then passed out.”

• Statements of fault are generally not admissible under 803(4):

  • “My boss negligently left the ladder unsecured.”
  • “The other driver ran a red light and was texting.”

Why? Knowing that someone was negligent is not necessary to treat the injury. But there is an important distinction:

• In some child abuse or domestic violence cases, knowing who inflicted the harm can affect treatment and safety planning (for example, removing the child from the abuser’s household, addressing psychological trauma).
• In those situations, courts often treat the identity of the abuser as medically relevant, and statements like “my stepfather did this” may be admissible under 803(4).

On the exam, ask:

• Does knowing the identity of the wrongdoer change or affect the medical plan (treatment, safety, counseling)?
  • If yes, it may be treated as “cause” and admitted.
  • If no, it is likely pure fault and excluded under this exception.

Statements to Whom? (Doctor vs. Others)

The rule does not limit admissibility to statements made to physicians.

Statements can be made to:

• Physicians (including specialists)
• Nurses, nurse practitioners, physician assistants
• Psychologists, psychiatrists, counselors, or social workers providing treatment
• Paramedics or EMTs responding to an emergency
• Other medical staff involved in diagnosis or treatment

They may even be made to non‑medical intermediaries if the declarant reasonably believes the information will be relayed to medical providers to obtain care. For example:

• A child tells her teacher, “My stomach hurts; my stepfather punched me last night.” The teacher immediately takes her to the school nurse and then to the hospital. The child’s statement may qualify because it was made for the purpose of getting help and treatment, and the declarant reasonably expects it will lead to medical care.

The exam focus remains on the medical purpose and relevance to treatment, not on professional titles.

Scope: Physical and Psychological Conditions

The exception covers statements about both physical and psychological conditions, as long as the link to diagnosis or treatment is clear.

Examples of physical‑condition statements:

• “My ankle swelled after I landed from a jump.”
• “I have had trouble breathing for three days.”

Examples of psychological‑condition statements:

• “I have been unable to sleep and feel constantly on edge since the assault.”
• “I keep reliving the car crash and avoid driving.”

Statements about emotional trauma, fear, anxiety, or other mental symptoms are often essential to diagnosis and treatment in mental health and trauma cases; they plainly fall within Rule 803(4).

Statements for Others

A statement may be admissible even if the speaker is not the patient, as long as the statement is made to obtain medical help for the patient and satisfies the other elements.

Examples:

• A babysitter rushes the child to the ER and says, “He drank some of the cleaning solution under the sink at 3 p.m.”
• A roommate calls an ambulance and tells the paramedics, “She took a handful of prescription pills about an hour ago.”

In both situations, the third party’s statement is reasonably relevant to diagnosis or treatment and made with the purpose of obtaining that care.

Statements to Non‑Treating Providers (Litigation Doctors)

Statements to medical professionals who are hired solely to testify in litigation (for example, an expert who examines the plaintiff only to give an opinion at trial) are a common exam trap.

• Many courts still admit the patient’s statements under 803(4) if they are reasonably relevant to diagnosis or treatment, even if the visit also has a litigation purpose.
• The key is whether the patient’s motive reasonably includes obtaining a medical opinion about diagnosis and prognosis—not solely fabricating a story for court.

On the MBE, if the plaintiff goes to a doctor solely because the lawyer told them to “help the case,” you should carefully analyze whether the exam is truly for diagnosis/treatment. If the fact pattern stresses litigation and not medical purpose, 803(4) may not apply.

Medical Records and Hearsay Within Hearsay

Another frequent exam pattern combines medical records with this exception:

• A hospital chart itself may be admissible as a business record under Rule 803(6).
• But the chart often contains multiple layers of hearsay:
  • The record (the chart) is one level;
  • The patient’s statements within the chart are another.

To admit the patient’s statements for their truth, you need both:

• 803(6) (business records) to admit the chart, and
• 803(4) (medical diagnosis or treatment) to cover the patient’s statements recorded in the chart.

If either layer lacks an exception, the statement cannot be used for its truth, though it might sometimes be used for a non‑hearsay purpose (for example, showing that the doctor was on notice of a complaint).

Confrontation Clause Considerations (Criminal Cases)

In criminal prosecutions, even if a statement fits Rule 803(4), the Sixth Amendment Confrontation Clause may still bar its admission against a defendant if:

• The statement is testimonial, and
• The declarant is unavailable, and
• The defendant had no prior opportunity to cross‑examine the declarant.

Most statements made to medical providers for diagnosis or treatment are considered non‑testimonial, because their primary purpose is medical, not to create evidence for trial. These generally do not raise a Confrontation Clause problem.

However, if the exam is clearly forensic in nature (for example, a government‑ordered evaluation conducted primarily to gather evidence against the defendant), the analysis may be different. The MBE will usually make that purpose obvious if it matters.

Worked Example 1.1

A patient arrives at the emergency room and says, “I was hit in the head by a falling brick and now I feel dizzy.” The doctor records this information in the medical chart. At trial, the plaintiff offers the doctor’s testimony about the patient’s statement to prove that the head injury came from a falling brick.

Answer:
Yes, the statement is admissible for its truth. It was made for the purpose of medical diagnosis or treatment, describes current symptoms (“I feel dizzy”) and cause (“hit in the head by a falling brick”), and is reasonably relevant to the doctor’s evaluation and care. It fits Rule 803(4).

Worked Example 1.2

A child is brought to the hospital by her aunt, who tells the nurse, “She fell off the playground slide and cannot move her arm.” The nurse notes this in the medical record. The aunt does not testify at trial. The plaintiff offers the nurse’s testimony to prove how the injury happened.

Answer:
The aunt’s statement is admissible under the medical diagnosis or treatment exception. The aunt spoke for the purpose of getting medical help for the child, and her description of the fall and the child’s inability to move her arm is reasonably relevant to diagnosis and treatment. The fact that the declarant is not the patient does not bar admissibility.

Worked Example 1.3

A patient tells the doctor, “My neighbor attacked me with a bat because he hates me.” The prosecution offers the statement in an assault trial to prove what happened and why.

Answer:
Only part of the statement is admissible under this exception. The phrase “attacked me with a bat” describes the cause of the injuries and is relevant to diagnosis and treatment, so it fits Rule 803(4). The motive part—“because he hates me”—is not medically relevant and is not covered by this exception. It might be inadmissible hearsay if offered for its truth to show motive.

Worked Example 1.4

A woman sees her friend collapse at a party. She calls 911 and tells the dispatcher, “He just grabbed his chest, said he felt a sharp pain, and then fell to the floor.” The dispatcher relays this information to paramedics, who treat the friend. At trial in a negligence action, the statement is offered to show the friend experienced chest pain before falling.

Answer:
The statement is admissible under Rule 803(4). The caller’s purpose is to obtain emergency medical help, and the information (sharp chest pain, sudden collapse) is important to diagnosis and treatment. The fact that the declarant is a bystander, not the patient, does not prevent application of the exception.

Worked Example 1.5

A 5‑year‑old child is examined by a pediatrician after school personnel notice bruises. The child tells the doctor, “Daddy hit me with a belt.” The prosecution in a child abuse case offers the doctor’s testimony about the child’s statement as proof that the father was the abuser.

Answer:
The statement is likely admissible under the medical diagnosis or treatment exception. The child is speaking to a doctor for treatment, and identifying the abuser can be reasonably relevant to diagnosis and treatment, especially for planning safety measures and addressing psychological harm. Although the statement also assigns fault, in child abuse cases courts commonly treat the identity of the abuser as medically relevant.

Worked Example 1.6

A plaintiff, at her lawyer’s suggestion, visits an orthopedic surgeon hired solely to testify for the plaintiff at trial. The surgeon does not prescribe any treatment but conducts an examination and asks, “How did this happen?” The plaintiff replies, “I slipped on grease in the defendant’s factory because they never clean the floors.” The plaintiff offers the surgeon’s testimony about the plaintiff’s statement for its truth.

Answer:
The part of the statement describing the mechanism of injury—“I slipped on grease in the defendant’s factory”—may be admissible if the court finds that the examination still served the purpose of medical diagnosis (understanding the mechanism can be important to evaluating the injury). The fault component—“because they never clean the floors”—is not medically relevant and is excluded under 803(4). On an exam, if the facts emphasize that the visit was purely for litigation, a court may find that the statement was not made for medical purposes and exclude it altogether under this exception.

Exam Warning

Statements assigning blame or legal responsibility are generally not admissible under this exception, unless knowing the identity of the wrongdoer is itself necessary to treatment (commonly in child abuse or domestic violence contexts). Focus on whether the disputed portion of the statement actually helps the provider treat or diagnose the condition.

Revision Tip

When working an MBE evidence question involving medical statements:

• Ask why the statement was made (medical help vs. litigation or other purpose).
• Ask what the statement covers: symptoms, history, or cause (usually admissible) versus fault (usually not).
• Ask who made the statement and whether it was given to someone who could or would help obtain medical care.
• Always remember hearsay‑within‑hearsay when the statement appears inside a medical record.

Key Point Checklist

This article has covered the following key knowledge points:

• Hearsay is an out‑of‑court statement offered for its truth and is generally inadmissible unless an exception applies.
• The medical diagnosis or treatment exception (FRE 803(4)) admits statements made for, and reasonably relevant to, medical diagnosis or treatment.
• The declarant can be the patient or a third party (such as a parent, caregiver, or bystander) if the statement is made to help obtain medical care.
• Admissible content includes symptoms, medical history, and cause or source of injury when relevant to treatment or diagnosis.
• Statements of fault or legal responsibility are generally not covered, unless identity of the wrongdoer is medically relevant (for example, in child abuse treatment).
• The statement need not be made to a physician; it can be made to any medical or mental health professional, paramedic, or intermediary where a medical purpose is clear.
• Medical records often involve hearsay within hearsay; the record may be a business record, while the patient’s statements inside must independently satisfy an exception such as 803(4).
• In criminal cases, statements made for medical diagnosis or treatment are usually non‑testimonial and do not violate the Confrontation Clause, though forensic‑only examinations may require closer analysis.

Key Terms and Concepts

• Hearsay
• Declarant
• Medical Diagnosis or Treatment Exception
• Reasonably Relevant
• Statement of Cause
• Statement of Fault