IN THE SUPREME COURT OF IOWA

No. 21–1319

Submitted December 14, 2023—Filed March 15, 2024

Amended March 26, 2024

STATE OF IOWA,

Appellee,

vs.

DAVID DWIGHT JACKSON,

Appellant.

On review from the Iowa Court of Appeals.

Appeal from the Iowa District Court for Polk County, Scott J. Beattie 

(motion to suppress) and David M. Porter (trial), Judges.

The defendant in a vehicular homicide case seeks further review of a court 

of appeals decision holding that rebuttal evidence of his medical condition was 

properly admitted over his hearsay objections. DECISION OF COURT OF APPEALS 

AFFIRMED IN PART AND REVERSED IN PART; DISTRICT COURT JUDGMENT 

AFFIRMED IN PART, REVERSED IN PART, AND REMANDED.

McDonald, J., delivered the opinion of the court, in which Oxley, 

McDermott, and May, JJ., joined. Mansfield, J., filed an opinion concurring in 

part and dissenting in part, in which Christensen, C.J., and Waterman, J., 

joined.

Gary Dickey of Dickey, Campbell, & Sahag Law Firm, PLC, Des Moines, 

for appellant.

Brenna Bird, Attorney General, and Bridget A. Chambers, Assistant 

Attorney General, for appellee.
2

MCDONALD, Justice.

David Jackson was involved in a car accident that killed another motorist. 

He was convicted of vehicular homicide by operating while intoxicated, reckless 

driving, leaving the scene of an accident resulting in death, and operating a 

motor vehicle without the owner’s consent. As relevant to this appeal, the 

primary issue at Jackson’s trial was the cause of the accident. The State 

contended Jackson was operating the vehicle while under the influence of 

controlled substances. Jackson testified that he blacked out and lost control of 

the vehicle due to a medical condition. To rebut Jackson’s testimony, the State 

called an employee of a healthcare vendor subcontracted to provide services to 

the county jail where Jackson had been detained after the car accident. The 

employee had not treated Jackson, but the employee had reviewed some of 

Jackson’s post-accident medical records that had been transmitted to the jail. 

Over Jackson’s hearsay objection, the district court allowed the employee to 

testify regarding the statements contained in the post-accident medical records 

even though the medical records were not offered or admitted into evidence. For 

the reasons expressed below, we conclude the district court erred in admitting 

the challenged testimony and the error was not harmless.

I.

Jackson was charged by trial information with homicide by vehicle 

(operating while under the influence), homicide by vehicle (reckless driving), 

leaving the scene of an accident resulting in death, theft in the second degree, 

and operating while under the influence, first offense. See Iowa Code 

§§ 707.6A(1), (2); id. § 714.2(2); id. § 321.261(4); id. § 321J.2(2)(a). The case was 

tried to a jury. The jury found Jackson guilty of homicide by vehicle (operating 

while under the influence) and guilty of leaving the scene of an accident resulting 

in death. The jury also found Jackson guilty of the lesser included offenses of 
3

reckless driving and operating a motor vehicle without the owner’s consent. See

id. § 321.277; id. § 714.7. The district court sentenced Jackson to a term of 

incarceration not to exceed twenty-five years. 

The trial record reflects the following. In July 2020, Patrick Downey 

reported his black Toyota Prius had been stolen. A woman renting from him or 

residing with him, Carrie Halfpop, had relapsed on drugs and had taken his car 

without his permission. On or about August 9, the Des Moines Police 

Department contacted Downey and told him that they had recovered his vehicle 

and that it had been in an accident. The driver of the vehicle at the time of the 

accident was David Jackson. Downey did not know Jackson, and Downey had 

not given Jackson permission to drive his vehicle.

Jackson testified that on August 9, he went a couple of doors down to his 

neighbors and asked to borrow Shelly Smith’s car. Jackson testified he needed 

to borrow the car to run some errands. One of Jackson’s errands was to go to 

Broadlawns Medical Center to get paperwork. Jackson testified that in the weeks 

prior to August 9, he had blacked out a couple of times. Jackson testified he had 

COVID-19 and had been quarantined from work. According to Jackson, he 

needed to get paperwork from Broadlawns to show he had taken a COVID-19

test so he could return to work and get paid for the time he was in quarantine. 

Smith allowed Jackson to take the vehicle. The vehicle Jackson borrowed from 

Smith was in fact Downey’s stolen Prius. Jackson testified he did not know the 

car was stolen. He testified he had seen Smith drive the car every day. After the 

car was recovered, Smith’s fingerprints were found in the Prius along with a 

woman’s boot and tampons. 

On August 9, Jackson was driving the Prius southbound on Martin Luther 

King Jr. Parkway in Des Moines near Broadlawns Medical Center. According to 

another motorist at the scene, the Prius was just “driving down the street” and 
4

“everything was just normal,” and then “[a]ll of a sudden,” the Prius accelerated 

and crossed the center lines into the northbound lanes. The Prius collided 

head-on with a Polaris Slingshot, a three-wheeled vehicle, being driven by 

Bounleua Lovan, and slammed it into a telephone pole. After the Prius collided 

with the Slingshot, the Prius jumped the curb, traveled through a parking lot, 

and kept going until it crashed into a building. The motorist testified he did not 

“see a brake light or [Jackson] even trying to stop the vehicle.” Based on this 

witness’s observation of the Prius, the witness “just assumed worst-case 

scenario, that it was somebody having, like, a medical problem . . . as they were 

driving down the street.” After seeing the accident, the motorist stopped his 

vehicle to check on Lovan. When the motorist got close to Lovan, he immediately 

knew it was not good. Lovan died from injuries sustained in the collision. 

Data from the Prius’s black box confirmed the eyewitness’s account of the 

Prius’s movements immediately preceding and during the accident. The data 

showed the gas pedal was depressed at a constant level of 68% to 68.5% from 

five seconds prior to colliding with the Slingshot until the Prius crashed into the 

building. The data showed the brakes were not applied at any time during the 

accident. The data showed the driver of the Prius did not jerk the wheel at any 

point during the accident. The State’s expert testified the steering wheel 

remained at a constant three degrees throughout the incident, which showed the 

driver had not attempted to “turn right or turn left.” In sum, the data showed 

“the driver was not moving the wheel, changing pedal position, or increasing 

speed by pushing the pedal down.” The State’s accident reconstruction expert 

testified he could not make a “determination that the person was intoxicated and 

that’s what caused this accident.” In this case, “there were no indicators, no 

factors, no reports given to” the expert “that made it possible . . . to come to a 

conclusion in that regard.”
5

Another motorist at the scene also saw the collision. After witnessing the 

collision, she drove toward the Prius to see if the driver was okay. A man exited 

from the driver’s side door. He “popped out kind of in a daze . . . just looking 

around as if he was confused a little bit.” When she asked if he was okay, the 

man replied, “I wasn’t in the vehicle. Wasn’t driving that vehicle.” But there was 

no one else in the vehicle. She testified the man got back into the vehicle and 

pulled out a bag. He started walking away from the scene with the bag. The 

witness called 911 and described the man as he was walking away from the 

scene. The witness subsequently identified Jackson as the man she had seen.

After Jackson left the crash scene, he walked a few doors down to a nearby 

senior living facility. He tried to enter the main entrance of the building. Unable 

to do so, Jackson sat down on a bench in front of the building. Officer 

Christopher Latcham was dispatched to the scene. Latcham encountered 

Jackson in front of the senior living facility and began to issue directives to him 

while holding a can of pepper spray. Jackson initially got on the ground, but he 

then got up and tried to run away. Latcham pepper-sprayed Jackson. After a 

short chase in front of the building, Jackson lied down on the ground. He was 

then placed in handcuffs by another police officer who had arrived at the scene, 

Officer Nathan Nemmers. Nemmers noticed that Jackson had bloodshot, watery 

eyes and was sweating profusely. Nemmers thought Jackson could be under the 

influence of drugs or alcohol. Nemmers did not smell any odor of an alcoholic 

beverage.

Jackson was transported to Broadlawns for treatment. He was given 

Ativan to calm him down. Nemmers questioned Jackson at the medical center. 

According to Nemmers, Jackson was “generally pretty incoherent.” Jackson 

denied having driven, denied knowledge of a collision, and was unable to tell 

Nemmers what had occurred. Nemmers was unable “to get any coherent 
6

response” from Jackson. Nemmers did not conduct any field sobriety tests at the 

hospital because Jackson “was incoherent and unable to follow . . . any 

commands or instructions.”

Nemmers applied for a search warrant to take a blood sample from 

Jackson. The application described the accident and recited Nemmers’s

observations of Jackson, summarizing them as follows:

Suspect was incoherent, unaware why he was at the hospital. 

Suspect was unaware that he had been involved in an accident. 

Suspect was displaying behavior consistent with drug use including 

profuse sweating, grinding teeth, and inability to remain still.

The warrant application contained an error. In preparing the search warrant 

application, Nemmers had modified a previous application form without deleting 

the information it contained about field sobriety tests. The search warrant 

application stated Jackson had failed the walk-and-turn and the one-leg-stand 

tests and had registered a .000 blood alcohol level on the preliminary breath test

even though no field sobriety tests had been administered. The district court 

issued the search warrant. 

After Jackson’s blood was drawn pursuant to the search warrant, the 

sample was sent for testing. Jackson’s blood tested positive for 

methamphetamine and amphetamine, at 104 nanograms per milliliter of blood 

and 16 nanograms per milliliter of blood, respectively. The State’s expert testified 

that methamphetamine and amphetamine can be obtained with a prescription 

and that both have therapeutic uses. He testified methamphetamine is “often 

used to treat obesity and narcolepsy and ADHD-type disorders.” There was no 

evidence on whether Jackson had a prescription for these drugs. Regardless, the 

State’s expert testified the level detected was above any therapeutic range. 

However, the State’s expert was unable to say that the levels in Jackson’s blood

“rendered Mr. Jackson intoxicated by methamphetamine.” 
7

Jackson admitted he had taken an ecstasy pill two or three days prior to 

the accident, but he believed the accident was due to his medical condition and 

not because he was under the influence. Jackson testified that while he was 

driving on August 9, he “started to have . . . tightness in [his] chest,” and he 

“passed out, blacked out at the wheel.” He “[c]ompletely blacked out at the 

wheel.” His “next memory [was] kind of like a pop, a bang, a loud noise, 

explosion,” and he found himself “sitting in the car” with the airbags deployed. 

He testified he “was in shock, actually, because [he] didn’t know where [he] was 

at or what had happened.” Jackson claimed that he didn’t realize he had run 

into another vehicle. He was in pain and was “trying to remember where [he] was 

at or what was going on.” He testified he saw a lady standing there when he 

exited the vehicle, but he couldn’t hear her or comprehend what she was talking 

about. He could not recall speaking to her. He was in “a generalized state of 

confusion at that point.” He decided he would try to walk to Broadlawns. He 

claimed that he mistook the senior living center for the medical center. He 

testified he could see “people in wheelchairs and a walker,” and he opened the 

front door but could not get through the locked lobby doors. Unable to get into

the building, he sat down outside. 

In support of his testimony, Jackson attempted to offer into evidence 

certain medical records from Broadlawns and his employer regarding COVID-19, 

quarantine, his testing, and his ability to return to work, etc. The prosecutor 

raised a hearsay objection, among others, to Jackson’s proffered exhibits. The 

prosecutor argued that the “defendant is not the witness to admit medical 

records.” The prosecutor argued that if a “records custodian from Broadlawns 

was here, that might be an appropriate witness,” or the doctor making the record 

might be an appropriate witness. The district court ruled one of the exhibits 

could be admitted but the remainder would be excluded due to lack of 
8

foundation, authentication, relevance, and hearsay. The one exhibit that was 

admitted was an authorization form to disclose health information to allow 

Broadlawns to release medical records, including lab results for COVID-19, to 

Jackson’s employer. The authorization form was signed by Jackson and dated 

July 27.

Almost immediately after the State argued to exclude Jackson’s medical 

and employment records on foundation and hearsay grounds, the State sought 

to introduce testimony about Jackson’s post-accident medical records. The State 

called Dale Peterson, who was employed as the health services administrator of 

a company called Wellpath. Wellpath was the contracted medical group for the 

Polk County Jail. As the health services administrator for Wellpath, Peterson 

oversaw the medical and mental health staff for the Polk County Jail. He was 

responsible for the medical records of persons in the jail. After Jackson was 

discharged from Broadlawns following the accident, he was arrested and 

transported to the Polk County Jail. Peterson testified that Broadlawns sent 

Jackson’s post-accident medical records to the jail. Peterson testified he reviewed 

the medical records. 

Over Jackson’s medical privilege, hearsay, and best evidence objections, 

Peterson was allowed to testify regarding the statements contained in the 

post-accident medical records and Jackson’s medical condition even though the 

medical records were not offered or admitted into evidence and even though 

Peterson had no personal knowledge regarding Jackson’s medical condition. 

Q. Can you tell us, please, if the defendant -- if his discharge 

instructions reflected any concerns about his breathing? 

A. No, ma’am, they did not.

Q. I didn’t ask you very well. I asked you if you could tell us 

and you said no. Did his records reflect that the defendant had any 

difficulty with his breathing? 
9

A. No, ma’am.

. . . .

Q. Do the records show, in Mr. Jackson’s case, whether or not 

he had vitals taken while he was at the hospital? 

A. Yes, they do.

Q. Do the records reflect what his heart rate was while he was 

at the hospital? 

A. Yes.

Q. What is that? 

A. From my understanding of his medical records after 

reviewing them, vital signs were stable and within normal limits.

. . . .

Q. What was the defendant’s oxygen level? 

A. 98 percent.

Q. Was there any report provided that the jail medical staff 

should make observations of the defendant for a history of blacking 

out? 

A. No, ma’am.

Q. A history of losing consciousness? 

A. No, ma’am.

The district court overruled Jackson’s privilege objection on the ground that the 

defendant “opened the door . . . during his direct examination.” The district court 

overruled the hearsay objection on the ground that the records either were not 

being offered for the truth of the matter asserted or involved Jackson’s 

statements of his own medical condition. See Iowa R. Evid. 5.803(3) (2021). The 

district court overruled the best evidence objection on the ground that “[t]his is 

not the type of testimony the best evidence rule is designed to regulate.” 
10

II.

Following the entry of sentence, Jackson filed this appeal. We transferred 

the case to the court of appeals. Jackson raised three arguments in his main 

brief on appeal. 

Jackson contended that the results of the chemical test of his blood should 

have been suppressed and not admitted at trial. Prior to trial, Jackson moved to 

suppress the blood test results on the ground that Nemmers’s search warrant 

application contained false information regarding field sobriety testing. See 

Franks v. Delaware, 438 U.S. 154, 155–56 (1978). Following a hearing, the 

district court denied the motion to suppress, reasoning that even if the false 

information were excised from the search warrant application, there was still 

sufficient information to establish probable cause to issue the warrant. The court 

of appeals affirmed the district court’s denial of the motion to suppress evidence. 

Like the district court, the court of appeals reasoned that even without the 

inaccurate information regarding field sobriety tests, “the other information in 

the [search warrant] affidavit support[ed] a probable cause finding.” See id. at 

171–72. 

Jackson next contended that the district court erred in allowing Peterson 

to testify about the statements contained in Jackson’s medical records. 

Specifically, Jackson contended his medical records and medical information 

were confidential and privileged pursuant to Iowa Code section 622.10. The 

court of appeals rejected the argument, concluding that Jackson waived 

confidentiality and privilege by testifying about his own medical condition and 

that the State was entitled to rebut Jackson’s testimony regarding his medical 

condition.

Finally, Jackson contended that the district court erred in allowing 

Peterson’s testimony because it violated the rule against hearsay. In the district 
11

court, the State contended Peterson’s testimony was not hearsay because it was 

not offered for the truth of the matter asserted but instead was offered to show 

the jail’s subsequent course of treatment. The district court allowed the 

testimony on that ground and on the alternative ground that the statements were 

admissible as statements of then-existing mental, emotional, or physical 

condition. 

In its appeal brief, the State abandoned the position that the testimony 

was not offered for the truth of the matter asserted and was not hearsay. Instead, 

the State argued that the testimony was admissible under three exceptions to 

the rule against hearsay: (1) statements of then-existing mental, emotional, or 

physical condition, see Iowa R. Evid. 5.803(3); (2) statements made for medical 

diagnosis or treatment, see id. r. 5.803(4); and (3) records of regularly conducted 

activity, also known as the business records exception, see id. r. 5.803(6). Even 

though some of these alternative arguments were not presented to the district 

court, an appellate court “may affirm a ruling on the admission of evidence by 

using a different rationale than relied on by the district court.” State v. Smith, 

876 N.W.2d 180, 184 (Iowa 2016). 

The court of appeals affirmed the district court’s admission of the 

challenged hearsay testimony. The court of appeals rejected the State’s argument 

that Peterson’s testimony was admissible as statements of then-existing mental, 

emotional, or physical condition under rule 5.803(3). The court of appeals 

reasoned that Peterson’s testimony did not recount Jackson’s statements about 

his condition but instead the statements of unknown persons who had observed 

Jackson. The court of appeals did not address the exception for statements made 

for purposes of medical diagnosis under rule 5.803(4). The court of appeals 

agreed with the State’s contention that Peterson’s testimony about the 
12

statements contained in the medical records was admissible under the business 

records exception to the rule against hearsay set forth in rule 5.803(6). 

III.

We granted Jackson’s application for further review. “On further review, 

we have the discretion to review any issue raised on appeal.” State v. Mong, 

988 N.W.2d 305, 308 (Iowa 2023) (quoting State v. Crawford, 972 N.W.2d 189, 

203 (Iowa 2022)). We exercise our discretion and confine our review to the 

question of whether Peterson’s hearsay testimony was admissible under the 

exceptions to the rule against hearsay set forth in rules of evidence 5.803(4) and 

5.803(6). The court of appeals decision is final as to all other issues.

A.

Hearsay is a statement that “[t]he declarant does not make while testifying 

at the current trial or hearing” and that is “offer[ed] into evidence to prove the 

truth of the matter asserted in the statement.” Iowa R. Evid. 5.801(c)(1)–(2). Iowa 

law prohibits the introduction of hearsay evidence unless an exception to the 

hearsay rule applies. See id. r. 5.802. The State concedes Peterson’s testimony 

was hearsay, but it argues that exceptions to the hearsay rule apply. The State, 

as the proponent of the evidence, bears the burden of proving an exception to 

the rule against hearsay applies. See State v. Walker, 935 N.W.2d 874, 879 (Iowa 

2019) (“ ‘The State, as the proponent of the evidence, has the burden’ to establish 

the testimony comes within the exception to the rule.” (quoting Smith, 

876 N.W.2d at 189)); State v. Cagley, 638 N.W.2d 678, 681 (Iowa 2001) 

(“The State, as proponent of the hearsay evidence, has the burden of proving it 

falls within an exception to the hearsay rule.”).

B.

The State first contends Peterson’s hearsay testimony was admissible as 

statements made for the purposes of medical diagnosis and treatment. See Iowa 
13

R. Evid. 5.803(4). We disagree. “The medical diagnosis or treatment exception 

imposes two requirements.” Smith, 876 N.W.2d at 185. First, the exception 

applies to the patient’s statements “made for purposes of medical diagnosis or 

treatment.” Id. (quoting Iowa R. Evid. 5.803(4)). “Second, the statements must 

describe ‘medical history, or past or present symptoms, pain, or sensations, or 

the inception or general character of the cause or external source thereof insofar 

as reasonably pertinent to diagnosis or treatment.’ ” Id. (quoting Iowa R. Evid. 

5.803(4)). Peterson’s testimony did not involve Jackson’s statements made for 

the purposes of medical diagnosis or treatment. Instead, Peterson’s testimony 

involved the statements of unknown providers who observed Jackson at 

Broadlawns. The exception is inapplicable here.

C.

The State contends, and the court of appeals agreed, that Peterson’s 

hearsay testimony was admissible under the business records exception to the 

rule against hearsay. See Iowa R. Evid. 5.803(6). We disagree. The rule provides 

for the admission only of “[a] record of an act, event, condition, opinion, or 

diagnosis” that would otherwise be disallowed by the rule against hearsay. Id.

(emphasis added). According to the text of the rule, the proponent of the evidence 

must show:

(A) The record was made at or near the time by—or from 

information transmitted by—someone with knowledge;

(B) The record was kept in the course of a regularly conducted 

activity of a business, organization, occupation, or calling, whether 

or not for profit;

(C) Making the record was a regular practice of that activity;

(D) All these conditions are shown by the testimony of the 

custodian or another qualified witness, or by a certification that 

complies with rule 5.902(11) or rule 5.902(12) or with a statute 

permitting certification; and
14

(E) The opponent does not show that the source of information 

or the method or circumstances of preparation indicate a lack of 

trustworthiness.

Id. (emphases added). It is clear from the plain language of the rule that it applies 

only to the admission of records as an exception to the rule against hearsay and 

not testimony about records in lieu of the records themselves. Indeed, we have 

said a “foundational element[]” of the rule is that the proffered evidence must be 

a “business record.” State v. Reynolds, 746 N.W.2d 837, 841 (Iowa 2008);

see also Beachel v. Long, 420 N.W.2d 482, 484 (Iowa Ct. App. 1998). In short, 

the rules of evidence create a “business records exception” to the rule against 

hearsay and not a “testimony about business records exception” to the rule 

against hearsay. See Bolin v. State, 736 So. 2d 1160, 1167 (Fla. 1999)

(per curiam) (“Oral testimony concerning business records is not admissible 

under this exception.”). 

Our conclusion that rule 5.803(6) does not allow testimony about business 

records in lieu of the records themselves is supported by federal precedents. Iowa 

rule 5.803(6) is the same as Federal Rule of Evidence 803(6). Because of the 

similarity between the two rules, “interpretations of the federal rule are often 

persuasive authority for interpretation of our state rule.” State v. Paredes, 

775 N.W.2d 554, 561 (Iowa 2009). Federal courts hold that the business records 

exception to the rule against hearsay permits the admission of business records 

and not oral testimony in lieu of the business records.

In United States v. Wells, the Fifth Circuit vacated a conviction for 

conspiracy to distribute cocaine because it found the admission of hearsay 

testimony reversible error. 262 F.3d 455, 457 (5th Cir. 2001). The government 

called a witness to testify regarding the contents of a destroyed drug ledger. Id.

at 459. The government argued that the business records exception permitted 

the testimony regarding the contents of the records. Id. The court disagreed and 
15

concluded this was reversible error. See id. at 462 (explaining it was reversible 

error to permit “hearsay testimony as to the contents of documents that were 

not themselves introduced into evidence” (quoting United States v. Marshall, 

762 F.2d 419, 428 (5th Cir. 1985))). Admitting testimony regarding the content 

of business records instead of the records themselves “would, in effect, be 

allowing an end run around the rule against hearsay and the requirements of 

the business records exception.” Id.

In United States v. Florez, the government called a DEA agent to testify 

regarding telephone records that connected the defendant to a drug courier. 

516 F. App’x 790, 793 (11th Cir. 2013) (per curiam). The government did not 

introduce the records themselves into evidence. Id. at 794. The Eleventh Circuit 

found this was error: “[Although] [t]he records would have been admissible as an 

exception against hearsay under Federal Rule of Evidence 803(6)(B), . . . there is 

no hearsay exception for testimony about records not in evidence. Thus, it 

appears that an error that was plain occurred with respect to the admission of 

the challenged portions of [the DEA agent’s] testimony.” Id. The Eleventh Circuit 

concluded not only that the district court committed error but also that the 

district court’s error was plain. 

Other federal courts are in accord with Wells and Florez. See F.D.I.C. v. 

Houde, 90 F.3d 600, 606 (1st Cir. 1996) (disallowing custodian whose “testimony 

might well have been sufficient to authenticate business records” from testifying 

regarding the content of documents where proponent “did not have any of the 

underlying documents with it at trial”); Folkerts v. Seterus, Inc., No. 17 C 4171, 

2019 WL 1227790, at *10 (N.D. Ill. Mar. 15, 2019) (stating that 

“the business-records exception found in Rule 803(6) is a mechanism by which 

a party may seek to admit the records themselves” and that “[i]t is not a 

mechanism for admitting testimony that is derived from the records, from 
16

individuals who otherwise lack personal knowledge”); Carlisle v. Nat’l Com. 

Servs., Inc., No. 1:14–CV–515–TWT–LTW, 2016 WL 4544368, at *4 (N.D. Ga. July 22, 

2016), (“Testimony regarding the contents of business records, unsupported by 

the records themselves, by one without personal knowledge of the facts 

underlying the records constitutes inadmissible hearsay.”); NRRM, LLC v. Mepco 

Fin. Corp., No. 10 C 4642, 2015 WL 1501897, at *10 (N.D. Ill. Mar. 27, 2015) 

(“[The defendant] is probably right that Rule 803(6) allows the admission only of 

the business records themselves, not testimony about records not in evidence.”); 

Kidd v. Jackson, No. 10–cv–4112 (SRN/SER), 2012 WL 6569293, at *3 (D. Minn. 

Dec. 17, 2012) (concluding that testimony about the contents of a document by 

someone who did not create the document is improper hearsay evidence); 

Boclair v. Beardan-Monroe, No. 10–cv–978–SCW, 2012 WL 3835874, at *4 (S.D. 

Ill. Sept. 4, 2012) (“The business record exception, however, only applies to the 

business record, not a witness’ testimony referencing facts found in the business 

record.”); Snowdon v. A.W. Chesterton Co., 366 F. Supp. 2d 157, 165 (D. Me. 

2005) (finding that testimony in the absence of the documents themselves was 

nothing more than hearsay); Bus. Info. Grp., Inc. v. Bell Atl. Sys. Leasing Int’l, 

Inc., No. 90 C 20291, 1992 WL 281367, at *3 (N.D. Ill. Oct. 8, 1992) (holding that 

business records exception did not permit testimony in lieu of the records); In re 

Sung Ho Cha, 483 B.R. 547, 553 (Bankr. 9th Cir. 2012) (noting that testimony 

“would run afoul of the hearsay rule if he testified regarding the specific 

provisions of the written document”).

We also find persuasive the decisions of numerous state courts that have 

interpreted business records exception to the rule against hearsay. Helton v. 

Bank of Am., N.A. concerned a foreclosure action. 187 So. 3d 245, 246 (Fla. Dist. 

Ct. App. 2016). A witness testified regarding the bank’s records that showed a 

notice of default had been sent to the mortgagor without the underlying records 
17

being admitted into evidence. Id. The court concluded this was error because the 

business records exception had not been met. It reasoned that “[w]hile the 

business records exception to the hearsay rule allows the admission of a 

memorandum, report, record, or data compilation, it does not authorize hearsay 

testimony concerning the contents of business records which have not been 

admitted into evidence.” Id. at 247 (quoting Thompson v. State, 705 So. 2d 1046, 

1048 (Fla. Dist. Ct. App. 1998)).

In State v. Cofer, the defendant challenged the admission of oral testimony 

establishing the price of a television he had stolen. 261 P.3d 1115, 1117 (N.M. 

Ct. App. 2001). The district court permitted a witness to testify regarding the 

price based on the witness’s review of business records. Id. The court found 

error. It concluded that “it is clear that the business records exception requires 

some form of document that satisfies the rule’s foundational elements to be 

offered and admitted into evidence and that testimony alone does not qualify 

under this exception to the hearsay rule.” Id. at 1119. 

In Ingles Markets, Inc. v. Martin, a supermarket was sued for a slip and fall 

accident occurring on its property. 513 S.E.2d 536, 537 (Ga. Ct. App. 1999). The 

supermarket offered into evidence testimony regarding a document that 

purported to show the floor was cleaned about twenty minutes before the 

incident. Id. at 538. However, the supermarket did not actually introduce the 

document into evidence. Id. The court held that the testimony was inadmissible 

hearsay. It found that “[t]estimony regarding the contents of business records, 

unsupported by the records themselves, by one without personal knowledge of 

the facts constitutes inadmissible hearsay.” Id.

Other state court decisions are in accord with Helton, Cofer, and Ingles 

Markets. See State v. Gallegos, No. 1 CA–CR 09–0653, 2010 WL 5058580, at *3 

(Ariz. Ct. App. Sept. 30, 2010) (“Moreover, the public and business records 
18

exceptions provide only for introduction of the record into evidence. They do not 

allow a witness to testify as to what the record states. ‘One having no 

independent knowledge cannot establish by oral testimony facts contained in a 

written record.’ ” (citation omitted) (quoting State v. Ceja, 546 P.2d 6, 8 (Ariz. 

1976) (en banc))); Barnes v. State, 739 So. 2d 1181, 1182 (Fla. Dist. Ct. App. 

1999) (per curiam) (“Here, although the court claimed it was relying on the 

business records exception to the hearsay rule, the state never sought to admit 

the file as a business record. Instead, the state offered only the probation officer’s 

testimony regarding the contents of the file. Consequently, the business records 

exception does not apply.” (citation omitted)); Thompson, 705 So. 2d at 1048 

(“While the business-records exception to the hearsay rule allows the admission 

of ‘[a] memorandum, report, record, or data compilation,’ it does not authorize 

hearsay testimony concerning the contents of business records which have not 

been admitted into evidence.” (quoting Fla. Stat. § 90.803(6)(a) (1995))); State v. 

Watkins, 224 P.3d 485, 492 (Idaho 2009) (stating “[i]n the absence of any 

document, . . . there was simply no ‘business record’ that might fall within this 

hearsay exception”); Bass v. Wash. Kinney Co., 457 N.E.2d 85, 96 (Ill. App. Ct. 

1983) (“[I]t is only the business record itself which is admissible, and not the 

testimony of a witness who makes reference to the record.”); State v. Cox, 

908 P.2d 603, 615 (Kan. 1995) (holding business records exception did not apply 

to testimony); State v. Johnson, No. A08–1138, 2009 WL 2150671, at *4 (Minn. 

Ct. App. July 21, 2009) (holding a witness may not testify as to the content of 

business records that are not admitted into evidence); State v. Cicerchi, 

915 N.E.2d 350, 360–61 (Ohio Ct. App. 2009) (“Although Evid. R. 803(6) permits 

introduction of records of regularly conducted activity, that exception concerns 

the introduction of the documents themselves, not oral testimony such as the 

witness for Novastar gave.”); Deep Keel, LLC v. Atl. Priv. Equity Grp., LLC, 
19

773 S.E.2d 607, 614–15 (S.C. Ct. App. 2015) (“The plain language of [South 

Carolina Rule of Evidence] 803(6) allows for the admission of ‘[a] memorandum, 

report, record, or data compilation,’ not testimony describing such a document. 

We hold Rule 803(6) does not apply to admit live testimony offered to prove the 

contents of a record containing hearsay when that record is not offered in 

evidence.”); C.J. Andrews, O.D., P.C. v. Tex. State Optical, Inc., No. 05–91–

00719–CV, 1992 WL 106026, at *2 (Tex. Ct. App. May 19, 1992) (“Likewise, this 

Court has said that oral testimony based on entries contained in written records 

without producing the source of such information is hearsay.”); Finn v. Finn, 

658 S.W.2d 735, 745 (Tex. Ct. App. 1983) (en banc) (“Oral testimony based on 

entries contained in written records without producing the source of such 

information is hearsay.”); Tripp v. Vaughn, 746 P.2d 794, 799 (Utah Ct. App. 

1987) (stating “testimony . . . cannot qualify as a business records exception” 

because “[t]he rule applies to written documents such as memoranda, records 

or reports and by its terms does not include oral statements”).

The dissent disagrees with our controlling precedents, the federal 

precedents, and other states’ precedents and concludes that the business 

records exception to the rule against hearsay permits hearsay testimony 

regarding business records without admission of the underlying records. The 

only case the dissent can find supporting this proposition is In re Lynch, 755 Fed. 

App’x 920 (11th Cir. 2018) (per curiam). In a summary judgment proceeding—

not trial—that court concluded a witness’s affidavit could be considered at 

summary judgment because she obtained personal knowledge of the company’s 

finances through reviewing the business’s financial records. Id. at 924. In a 

footnote, the panel expressed its disagreement with Florida law (cited above) 

regarding the business records exception. Id. at 924 n.4. Lynch is an outlier 
20

decision. It is contrary to all other federal decisions and to the leading treatise 

on the federal rules of evidence, Federal Practice and Procedure:

Given the language of Federal Rule of Evidence 803(6) [(the 

business records exception)], courts generally assume that the 

business “record” itself must be introduced, not solely testimony 

about the contents of a qualifying record. Although largely unnoticed 

in commentary, the rules’ drafters seem to purposefully alternate 

between exceptions that cover “a statement” and others that cover 

“a record”; a point driven home by Rule 803(8) which covers a 

“record or statement.” Consequently, for exceptions like Rule 803(6) 

that explicitly cover only a “record,” it would appear that the drafters 

intended that the record itself, as opposed to testimony about the 

record or statements contained within the record, would be 

introduced under the exception. 

30B Charles Alan Wright & Jeffrey Bellin, Federal Practice and Procedure § 6868, 

West (database updated Apr. 2023) [hereinafter Federal Practice] (footnote 

omitted). 

We adhere to our controlling precedents and follow the persuasive 

precedents and the leading treatise. The business records exception to the rule 

against hearsay allows for the admission of business records and not testimony 

in lieu of the business records. Because the State, as proponent of the evidence, 

failed to establish an exception to the rule against hearsay, we conclude the 

district court erred in admitting the challenged testimony. While Peterson’s 

testimony may also have violated the best evidence rule, see Wright & Miller 

§ 6868 (“Testimony about a business record that is not itself introduced into 

evidence could also trigger a ‘best evidence’ objection under Federal Rule of 

Evidence 1002.” (emphasis added)), we need not reach that argument to resolve 

this appeal. 

D.

The dissent also contends that Jackson waived or forfeited this argument 

on appeal. The dissent misapplies our law regarding waiver and forfeiture. 
21

A party forfeits an issue on appeal when the party does not include the issue in 

its main brief. See State v. Erdman, 996 N.W.2d 544, 551 n.2 (Iowa 2023); 

Goodenow v. City Council, 574 N.W.2d 18, 27 (Iowa 1998). A party forfeits an 

issue on appeal when the party fails to clearly identify an issue on appeal. See 

Goode v. State, 920 N.W.2d 520, 524 (Iowa 2018). A party forfeits an issue on 

appeal when the party fails to make an argument in support of the issue. See 

State v. Vaughan, 859 N.W.2d 492, 503 (Iowa 2015); State v. Short, 851 N.W.2d 

474, 479 (Iowa 2014). A party forfeits an issue on appeal when the party fails to 

make more than a perfunctory argument in support of the issue. See State v. 

Tyler, 867 N.W.2d 136, 166 n.14 (Iowa 2015). A party forfeits an issue on appeal 

when the party fails to cite any authority in support of the issue. See Iowa R. 

App. P. 6.903(2)(g)(3) (2021). And, with respect to state constitutional claims, a 

party forfeits an issue on appeal when the party fails to develop his state 

constitutional claim in any meaningful way. See In re V.H., 996 N.W.2d 530, 537 

(Iowa 2023). None of these rules of forfeiture are applicable here.

Jackson did all he needed to do to present his hearsay argument on 

appeal. He argued in his main brief that Peterson’s testimony violated the rule 

against hearsay. The State concedes Peterson’s testimony was hearsay and its 

admission violated the rule against hearsay unless an exception applied. 

Because this case involves an evidentiary ruling, the State, as proponent of the 

evidence, was allowed to introduce new grounds on appeal to affirm the district 

court’s ruling even though the grounds were not raised in the district court. See 

Smith, 876 N.W.2d at 184. Jackson, as the appellant, had no obligation in his 

main brief to anticipate what those grounds might be and prebut any and all 

arguments the State could have raised in its brief. Further, Jackson had no 

obligation to file a reply brief to rebut the arguments in the State’s brief. See Iowa 

R. App. P. 6.903(4) (stating a party “may” file a reply brief).
22

Once Jackson established Peterson’s testimony violated the rule against 

hearsay (as the State concedes he did), the State, as the proponent of the 

evidence, had the burden of establishing each of the elements of an exception to 

the rule against hearsay regardless of Jackson’s response, if any, in his reply 

brief. See Walker, 935 N.W.2d at 879; Smith, 876 N.W.2d at 189; Cagley, 

638 N.W.2d at 681; see also United States v. Irvin, 682 F.3d 1254, 1262 

(10th Cir. 2012) (stating the opponents of the evidence had “no obligation to 

affirmatively disprove the applicability of the business records exception” 

because “[t]he burden was on the government alone”); Berroteran v. Superior Ct., 

505 P.3d 601, 620 (Cal. 2022) (concluding intermediate appellate court erred 

when it “shifted the burden of proof concerning this hearsay exception to the 

opponent of the evidence”); Martinez v. State, 178 S.W.3d 806, 815 (Tex. Crim. 

App. 2005) (“Appellant objected to the testimony as hearsay; it was hearsay, and 

thus his objection was both proper and sufficient. If the testimony fit some 

exception or exemption to the hearsay rule[,] . . . the State, as the proponent of 

the evidence, had the burden of demonstrating the applicability of that 

exemption or exception.” (footnote omitted)).

We may affirm an evidentiary ruling on a new ground raised on appeal 

only if there is a “proper basis” for doing so. State v. Maxwell, 743 N.W.2d 185, 

192 (Iowa 2008) (“We are obliged to affirm an appeal where any proper basis 

appears for a trial court’s ruling, even though it is not one upon which the court 

based its holding.” (quoting Citizens First Nat’l Bank v. Hoyt, 297 N.W.2d 329, 

332 (Iowa 1980) (en banc))). Because the state failed to establish an element of 

the business records exception to the rule against hearsay—that the proffered 

evidence was a record—there is no “proper basis” to affirm the admission of 

Peterson’s hearsay testimony under this exception. See Federal Practice § 6803 

(“The proponent of the statement, however, ‘bears the burden of proving each 
23

element of a given hearsay exception or exclusion.’ ” (quoting United States v. 

Day, 789 F.2d 1217, 1221 (6th Cir. 1986))). The dissent’s contention that we 

could affirm the admission of concededly hearsay testimony under an exception 

clearly not applicable is without merit.

IV.

When the district court erroneously admits hearsay into evidence, as it did 

here, “[w]e presume prejudice—that is, a substantial right of the defendant is 

affected—and reverse unless the record affirmatively establishes otherwise.” 

State v. Newell, 710 N.W.2d 6, 19 (Iowa 2006) (quoting State v. Sullivan, 

679 N.W.2d 19, 30 (Iowa 2004)). The record affirmatively establishes lack of 

prejudice if the record shows the hearsay evidence did not affect the jury’s finding 

of guilt. See State v. Elliott, 806 N.W.2d 660, 669 (Iowa 2011). “One way to show 

the tainted evidence did not have an impact on the jury’s verdict is to show the 

tainted evidence was merely cumulative.” Id. Another way “the State can 

overcome this presumption is through overwhelming evidence of the defendant’s 

guilt.” State v. Skahill, 966 N.W.2d 1, 15 (Iowa 2021).

The record does not affirmatively establish a lack of prejudice with respect 

to three of Jackson’s convictions. For the charge of vehicular homicide (OWI), the 

State was required to prove Jackson’s intoxication caused the death of Lovan. 

For the charge of reckless driving (Jackson was acquitted of vehicular homicide, 

reckless driving), the State was required to prove Jackson drove in a reckless 

manner. For the charge of leaving the scene of an accident resulting in death, 

the State was required to prove Jackson knew the accident resulted in injury or 

death to another person. Jackson’s medical condition—specifically, whether he 

blacked out—was a critical piece of evidence bearing on each of these charges. 

Peterson’s hearsay testimony offered to rebut Jackson’s testimony was not 

cumulative of other evidence; there was no other evidence admitted regarding 
24

Jackson’s medical condition. This is also not a case of overwhelming evidence. 

An eyewitness said it looked like the driver of the Prius suffered a medical issue. 

The data from the car—showing Jackson did not swerve or brake—seems more 

consistent with a medical emergency than with intoxication. The State’s expert 

on accident reconstruction could not opine that the cause of the accident was 

intoxication. And the State’s toxicologist could not opine that Jackson was 

intoxicated based on the chemical blood test. We thus must vacate Jackson’s 

convictions for these offenses.

We reach a different conclusion with respect to Jackson’s conviction for 

operating a motor vehicle without the owner’s consent. On this charge, the State 

was required to prove Jackson took possession and control of the vehicle without 

the owner’s consent. Jackson testified he had possession and control of the 

vehicle and that he took the vehicle to run errands. Downey testified that 

Jackson did not have permission to use his vehicle. Jackson testified that he 

blacked out while he was driving on Martin Luther King Jr. Parkway, after he 

already had taken possession and control of the vehicle for his own purposes. 

Jackson’s blackout while driving, even if true, had no bearing on whether he 

initially took possession and control of the vehicle without the owner’s consent.

V.

For these reasons, the decision of the court of appeals is affirmed in part 

and reversed in part. We affirm Jackson’s conviction for operating a motor 

vehicle without the owner’s consent. We vacate Jackson’s convictions for 

vehicular homicide (OWI), reckless driving, and leaving the scene of an accident 

resulting in death. We remand this case for further proceedings.

DECISION OF COURT OF APPEALS AFFIRMED IN PART AND REVERSED IN 

PART; DISTRICT COURT JUDGMENT AFFIRMED IN PART, REVERSED IN PART,

AND REMANDED.
25

Oxley, McDermott, and May, JJ., join this opinion. Mansfield, J., files an 

opinion concurring in part and dissenting in part, in which Christensen, C.J., 

and Waterman, J., join.
26

#21–1319, State v. Jackson

MANSFIELD, Justice (concurring in part and dissenting in part).

I would affirm the convictions and sentence in this case. I believe that all 

of David Jackson’s appellate arguments are without merit. The majority reverses 

on a ground not argued by Jackson.

This case presents the not-unusual circumstance where a defendant 

charged with a serious crime takes the stand and claims, for the first time, that 

he “blacked out” at the time of the alleged offense. Jurors have to weigh this 

defense: Did the defendant really black out or does the defendant simply not 

want to face what happened or, perhaps, lack a good explanation for it? And 

prosecutors sometimes have to scramble to rebut this defense.

Here, the prosecution responded by calling the health services 

administrator at the Polk County Jail to testify that Jackson’s medical records, 

of which Dale Peterson was the custodian at the jail, were at odds with Jackson’s 

self-proclaimed medical history. Jackson’s counsel made a series of objections 

below to Peterson’s testimony but didn’t argue that the records needed to be 

produced in lieu of testimony. Nor does Jackson’s appellate counsel in the 

current appeal. The majority grants what Jackson does not seek.

I. Putting the Peterson Testimony in Context.

Some additional factual context from this case is helpful. While I would 

not argue that any error in the admission of Peterson’s testimony would have 

been harmless, there was substantial evidence that the defendant was under the 

effects of methamphetamine at the time of the accident and little corroboration 

or consistency for his claim of a blackout.

Not mentioned by the majority is that Jackson’s behavior after the accident 

was largely caught on surveillance video. The video shows Jackson walking 

briskly away from the scene of the accident with his gym bag that he had pulled 
27

out of the vehicle. Upon reaching a nearby senior living center, Jackson entered 

the foyer. He looked behind himself nervously and repeatedly as if to check if 

anyone was following him. He pulled on the door and hit a buzzer to try to enter 

the building. Unable to do so, Jackson shuffled through his gym bag, pulled a 

baseball cap out, put the hat on, and sat down on a bench in front of the building 

with two women who were previously there.

Officer Christopher Latcham received a description of the driver who had 

fled from the wrecked Prius. On his bodycam, Officer Latcham is shown asking 

for assistance and being directed to the bench in front of the senior living senior 

center. Officer Latcham encountered Jackson in front of the senior living center 

and began to question him. Jackson asked, “What’s wrong?” When Jackson 

started to run, Officer Latcham chased after him and pepper-sprayed him. 

Jackson was subdued and handcuffed by another police officer, Officer Nathan 

Nemmers. Officer Nemmers noticed that Jackson “had bloodshot, watery eyes, 

seemed a little paranoid,” and was “sweating profusely.” Officer Nemmers 

thought that Jackson could be under the influence of drugs or alcohol, but he 

did not smell any odor of an alcoholic beverage. As it turned out, Jackson had 

methamphetamine in his blood.

At trial, Jackson took the stand in his own defense. Jackson acknowledged 

that he had lost his driving privileges at the time of the accident. He said he had 

borrowed the Toyota Prius from a friend to run a couple of errands, specifically 

to stop by his daughter’s house to see if she was going to be able to pick him up 

from work the next day and to stop by another friend to see if he was going to 

come by later on. This probably seemed a little odd to the jury: Why not just call 

the friend and the daughter if you need to ask these brief questions instead of 

driving illegally to go see them? But Jackson’s counsel then changed the subject 
28

and asked, “You stated, however, you needed to get a note for work; is that 

correct?” 

Actually, no one had referred to a note for work until Jackson’s counsel 

raised the subject. Counsel then led Jackson through some more questioning 

until Jackson testified that he was heading to Broadlawns at the time of the 

accident to get a note so he could return to work. According to Jackson, he had 

been in quarantine for possible exposure to COVID-19 and needed a note from 

Broadlawns to go back to work the next morning—August 10, 2020.

Jackson claimed that he felt fine on August 9 but that he had blacked out 

a couple of times in the recent past. According to Jackson, a third blackout 

occurred that evening of August 9 and caused him to have the accident. 

Suddenly, while driving on Martin Luther King Jr. Parkway that evening, 

Jackson “started to have . . . tightness in [his] chest,” and he “passed out, 

blacked out at the wheel.” According to Jackson, he lost consciousness for only 

a matter of seconds—from just before until just after the collision with the 

Slingshot. Jackson testified to having no memory of the collision itself.

Jackson claimed that when he came to, he didn’t realize that he had 

collided with another vehicle. According to Jackson, his head was throbbing and 

his ears were ringing. After exiting the vehicle, he decided to try to walk to 

Broadlawns. He claimed that he mistook the senior living center for Broadlawns.1

He said he did not believe he was impaired or intoxicated while driving that 

evening, although he had taken an ecstasy pill two or three days earlier.2 He 

believed his condition on August 9 was due to blacking out and had no 

1I suspect that a Polk County jury would have had members who were familiar with 

Broadlawns. They would have drawn their own comparison between Broadlawns and the senior 

apartment building shown on video.

2Jackson had no ecstasy in his system, and he claims the pill must have contained 

methamphetamine.
29

connection to any substances in his blood. According to Jackson, he was not 

intoxicated on anything “[b]esides Gatorade maybe.” 

Jackson also testified that upon being transported to Broadlawns on 

August 9, he was admitted to the ICU. He said his heart rate had reportedly 

dropped to 34, and “[t]hey said they were waiting to see if [his] heart was going 

to stop again.”

Jackson sought to introduce three exhibits. One, which was admitted, was 

an authorization dated July 27, 2020, for Broadlawns to release COVID-19 

testing information to Jackson’s employer. Another document, which was not 

admitted on grounds of lack of foundation, authentication, relevance, and 

hearsay, was apparently a standard guidance for persons exposed to COVID-19. 

The third document was not admitted for the same reasons and apparently 

related to the same subject.3

Having had no prior notice of Jackson’s “blackout” defense, the State 

summoned Peterson to testify as a rebuttal witness the next morning. Peterson 

was the health services administrator of the Polk County Jail and the custodian 

there of Jackson’s medical records. Peterson testified that when Jackson arrived 

at the jail on August 10, certain medical records came with him from 

Broadlawns. Over Jackson’s objections, Peterson testified regarding the contents 

of those records and the records of the initial screening performed at the jail. The 

district court overruled Jackson’s privilege objection on the ground that “the 

defendant . . . opened the door . . . during his direct examination.” The district 

court overruled the best evidence objection on the ground that “[t]his is not the 

type of testimony the best evidence rule is designed to regulate.” The district 

court overruled the hearsay objection on the ground that the records either were 

3The defendant did not include the actual unadmitted exhibits in an offer of proof.
30

not being offered for the truth of the matter asserted or involved Jackson’s 

statements of his own medical condition. See Iowa Rs. Evid. 5.801(c)(2), 5.803(3).

According to Peterson, Jackson’s records did not indicate that he was 

having difficulty breathing; they showed stable vital signs within normal limits, 

and they reflected a normal oxygen level. There was no indication in the records 

that Jackson had any problems with blacking out. The records also mentioned 

that precautions were being taken for alcohol and opioid detoxification. 

According to Peterson, any implementation of those precautions would have been 

based on statements made by Jackson to jail staff.

II. The Contents of Jackson’s Medical Records Were Not Inadmissible 

Hearsay.

As I’ve noted, Jackson’s complaint is not that Peterson testified to the 

contents of Jackson’s medical records. It is that the contents of those records 

came into evidence at all.

In overruling this objection, the district court did not err, although I 

disagree somewhat with its legal rationale. Medical records are often business 

records, even when generated by another medical facility. 

Iowa Rule of Evidence 5.803(6) (2021) provides a hearsay exception for:

(6) Records of a regularly conducted activity. A record of an act, 

event, condition, opinion, or diagnosis if:

(A) The record was made at or near the time by—or from 

information transmitted by—someone with knowledge;

(B) The record was kept in the course of a regularly conducted 

activity of a business, organization, occupation, or calling, whether 

or not for profit;

(C) Making the record was a regular practice of that activity;

(D) All these conditions are shown by the testimony of the 

custodian or another qualified witness, or by a certification that 
31

complies with rule 5.902(11) or rule 5.902(12) or with a statute 

permitting certification; and

(E) The opponent does not show that the source of information 

or the method or circumstances of preparation indicate a lack of 

trustworthiness.

In State v. Buelow, we recently reversed a murder conviction because the 

decedent’s mental health records had been improperly excluded at trial. 

951 N.W.2d 879, 890 (Iowa 2020). The defendant claimed that the decedent had 

committed suicide. Id. at 883. In the course of our opinion, without detailed 

analysis, we concluded that the decedent’s “medical records [were] admissible 

hearsay under the exception for records of a regularly conducted activity.” Id. at 

884 (citing Iowa R. Evid. 5.803(6)).

As one commentator has explained,

As anyone who has visited a doctor’s office or emergency 

room--or urgent care clinic, ambulatory surgical center, or strip mall 

imaging operation--can attest, modern medicine is very much a 

business. It is unsurprising, then, that “[m]edical records can be 

offered into evidence under the business records exception, provided 

the party offering the records for admission can meet the 

requirements set forth in Rule 803(6).” Such records neatly fit 

within the Rule’s definition. Medical practitioners usually have 

direct knowledge of the condition, activity, or diagnosis. They 

prepare records at or around the time of examination, particularly 

as inputting information into EHRs on tablets, laptops, or floating 

workstations becomes nearly universal. Furthermore, they are in 

the business of conducting medical examinations and diagnosing 

and treating medical conditions. Likewise, the presumption of 

trustworthiness created by the need to run an effective business is 

also present with respect to medical records.

Paul W. Kaufman & Christopher J. Merken, Toward a Presumptive Admission of 

Medical Records Under Federal Rule of Evidence 803(4), 64 B.C. L. Rev. 567, 

600–01 (2023) (alteration in original) (footnotes omitted) (quoting Tucker v. 

Nelson, 390 F. Supp. 3d 858, 863 (S.D. Ohio 2019)). 
32

Furthermore, “[t]his principle has also been extended to the admission of 

records from other businesses under what we call the ‘business-reliance 

doctrine’: when the records of Business A include and rely upon the business 

records of Business B, B’s business records are admissible as A’s business 

records.” Id. at 604. In other words: “A document prepared by a third party may 

qualify as another business entity’s business record under [the business records 

exception] if that entity integrated the third-party record into its records and 

relied upon it in its day-to-day operations.” Makor Issues & Rts., Ltd. v. Tellabs, 

Inc., 735 F. Supp. 2d 856, 867 n.2 (N.D. Ill. 2010). 

For example, the United States Court of Appeals for the Fifth Circuit 

upheld the introduction of invoices “received and held” by a company over a 

hearsay objection. United States v. Flom, 558 F.2d 1179, 1182 (5th Cir. 1977). 

While “[n]o testimony of the preparing company was offered,” the receiving 

company testified that the “invoices were received and held in the regular course 

of business.” Id. Thus, the invoices also constituted business records of the 

receiving company. See id.; see also United States v. Childs, 5 F.3d 1328, 1333 

(9th Cir. 1993) (“Several circuits have held that exhibits can be admitted as 

business records of an entity, even when that entity was not the maker of those 

records, so long as the other requirements of Rule 803(6) are met and the 

circumstances indicate the records are trustworthy.”); Bank of N.Y. Mellon v. 

Shone, 239 A.3d 671, 677 (Me. 2020) (“Multiple federal circuit courts and 

numerous other states have upheld the admission of integrated business records 

upon a showing of verification and reliance on the part of the receiving business, 

without the need for testimony from the originating business.”).

The concept of integrated business records can also apply to medical 

records. As one treatise puts it, “[T]he custodian of the hospital records may lay 

a foundation from the ambulance records found in the patient’s file.” 7 Michael 
33

H. Graham, Handbook of Federal Evidence § 803:6, at 354 (9th ed. 2020). “The 

MRI report received on the medical internet is not a record generated by the 

hospital itself. Here, however, like the ambulance report because the hospital 

relies upon this record[] and concurs in its recommendation upon making its 

own assessment, the MRI is treated the same as any other part of the patient’s 

medical file.” Id. Professor Graham concludes, “It is not required that the 

custodian have personal knowledge of the matters recorded, or of the persons 

creating the records, or the medical procedures regularly followed.” Id. at 353.

Consider the following case from Washington. In State v. Ziegler, a doctor 

from a medical center testified regarding the victim’s lab test results under the 

business records exception. 789 P.2d 79, 81 (Wash. 1990) (en banc). The 

defendant appealed, arguing that the test results were business records of the 

lab rather than the medical center and that the doctor could not testify to them. 

Id. at 82.

The Washington Supreme Court disagreed. Id. It considered the following 

facts in making its decision that the results were admissible as business records 

of the medical center: 

[The] treating physician ordered the . . . tests and relied upon the 

test results in his treatment of the child. The record was in the 

custody of [the medical center] as part of [the victim’s] medical file. 

[The doctor] testified regarding his familiarity with the laboratory 

and its testing procedures. 

Id. at 83. 

I now turn to whether the elements of the business records exception were 

met in this case. Note that there are three preconditions to admissibility: 

paragraphs (A), (B), and (C) of rule 5.803(6). Note also that these conditions can 

be met by the testimony of “the custodian or another qualified witness.” Iowa R. 
34

Evid. 5.803(6)(D). In other words, the custodian doesn’t have to lay all the 

foundation.

To begin, Peterson testified that he was “responsible for . . . the medical 

business records . . . that are kept with respect to individuals in the Polk County 

Jail.” See id. He agreed that he was “the custodian.” Id. Peterson also testified 

that when a person comes to the jail from a medical facility, the jail receives 

“discharge instructions for the patient and the actual discharge from the hospital 

for the patient.” He also receives other medical records showing “treatment 

provided.” This is important “if a patient has issues or medical concerns that 

need to be addressed.” In other words, the jail relies on these records. These 

incoming medical records are then maintained by the jail as part of its own 

records. Thus, Peterson’s testimony established that it is a regular practice of 

the jail to receive certain regularly maintained records of the medical facility 

which the individual comes from. See id. r. 5.803(6)(B)–(C).

Additionally, Peterson testified that the records were transmitted from 

Broadlawns electronically on August 10 when Jackson was admitted to the jail. 

Since Jackson had been taken to Broadlawns on the evening of August 9, the 

records would have been created contemporaneously or nearly 

contemporaneously with the conditions that were recorded. See id. r. 5.803(6)(A). 

There was also independent evidence that Jackson received medical treatment 

at Broadlawns that evening. Jackson testified that he did so and that 

Broadlawns determined that his heart rate had dropped. Also, Officer Nemmers 

testified that upon his arrival at the hospital, “some medical personnel were still 

attending to [Jackson].” Photographs were admitted showing Jackson on a 

hospital bed. Thus, the record supports an inference that any medical history 

and vital signs taken from Jackson would have been recorded by a person with 

knowledge. Id.
35

Peterson testified that the medical records from Broadlawns didn’t reflect 

any concerns about breathing difficulties or a history of blacking out and that 

they showed his vital signs were stable and his blood oxygen level was normal. 

This is the type of information that would have been recorded by a person with 

a motivation to be accurate and no motivation to be inaccurate. 

Of course, even if proper foundation is laid for medical records to be 

admitted, “this does not necessarily make everything in the records admissible.” 

In re Est. of Poulos, 229 N.W.2d 721, 727 (Iowa 1975). For example, there could 

be hearsay within hearsay in the medical records. See id.

But here, the items referred to above—vital signs and medical history—

would have been based either on firsthand recorded observations or on 

statements made by Jackson. There is therefore no hearsay-within-hearsay 

problem. See id. Nor has Jackson pointed to any source, method, or 

circumstance indicating a lack of trustworthiness. See Iowa R. Evid. 5.803(6)(E).

Madison v. Colby, 348 N.W.2d 202 (Iowa 1984) (en banc), cited by Jackson, 

is distinguishable. We held there that a hearsay objection should have been 

sustained when the defendants sought to offer the report of one doctor through 

the testimony of another doctor. Id. at 204. As we explained, “First, if offered as 

a business record of Dr. Hall to prove assertions of Dr. Routman, exclusion 

would be required under the ‘hearsay within hearsay’ or double hearsay rule.” 

Id. Moreover, we added, “the defendants failed to show that Dr. Routman’s record 

was made in the regular course of business at or about the time of the events 

recorded or that the sources of information and method of preparation were such 

as to indicate its trustworthiness.” Id.

The present case is different. The State proved both that the discharge 

records had been made at or about the time of the events recorded by persons 

with firsthand knowledge and that it was a regular practice for these records to 
36

have been prepared and turned over to the jail. In Madison, by contrast, the 

second doctor simply testified “that he obtained [the first doctor’s] record to 

assist him in treating [the plaintiff].” Id. at 203–04. The foundation for admission 

of an integrated business record was not laid in Madison.

There is one other aspect of Peterson’s testimony regarding the medical 

records that I have not discussed. Peterson also testified that the jail records 

reflected that Jackson was immediately placed on detox precautions. According 

to Peterson, that was a regular practice of the jail “[a]ny time a patient [upon 

arrival] states daily use or use of opioids or alcohol more than one to five days a 

week.” Hence, Peterson’s testimony confirmed that the information that would 

have been regularly and contemporaneously recorded in the regular course of 

activity of the jail based on statements made by the defendant. See Iowa R. Evid. 

5.803(6)(A)–(C).

There remains the issue of trustworthiness with respect to the jail protocol. 

It is the opponent’s burden to “show that the source of information or the method 

or circumstances of preparation indicate a lack of trustworthiness.” Id.

r. 5.803(6)(E). Here, at least, the record does not indicate that this was an 

untrustworthy way to prove that an inmate had acknowledged prior opioid or 

alcohol use.

The foregoing discussion addresses the entirety of Jackson’s hearsay 

argument on appeal. And because that argument lacks merit and the majority 

has let the court of appeals decision stand on everything else, Jackson’s 

convictions and sentence should be affirmed. 

III. The Majority Reverses on a Ground Not Argued by Jackson.

The majority reverses most of Jackson’s convictions on a ground not urged 

by Jackson. According to the majority, while the jail medical documents 

themselves may have been admissible, it was error for Peterson to testify about 
37

them. I think the majority raises a legitimate theoretical point, but not one that 

is part of this appeal.

One might say the problem raised by the majority has to do with the “best 

evidence” rule, not the hearsay rule. That rule provides, “An original writing, 

recording, or photograph is required to prove its content, unless these rules or a 

statute provides otherwise.” Iowa R. Evid. 5.1002. The State sought to prove the 

content of Jackson’s medical records, not through the records themselves, but 

through the testimony of Peterson. 

Using Peterson to testify to what the records said isn’t a separate hearsay 

problem; Peterson has firsthand knowledge of the records themselves and is 

available for cross-examination. However, it is potentially a violation of the best 

evidence rule. See In re Est. of Cory, 169 N.W.2d 837, 847 (Iowa 1969) (holding 

that an objection should have been sustained when “Dr. Nord referred to the 

contents of an autopsy report over timely objection that his testimony was not 

the best evidence”); 6 Mark S. Brodin et al., Weinstein’s Federal Evidence

§ 1002.05[1], at 1002-15 to 16 (2d ed. 2023) (“[T]he rule does apply when a 

witness seeks to testify about the contents of a writing, recording, or photograph 

without producing the physical item itself.”); 2 Robert P. Mosteller et al., 

McCormick on Evidence § 234, at 140 (8th ed. 2020) (explaining that when a 

testifying witness is “relying on a writing, recording or photograph that the 

witness has read or observed outside of court,” and “the proponent of the 

witness’s testimony does not present that document in court, there is likely to 

be a violation of the best evidence rule”). 

The majority does collect a body of cases saying that you need to introduce 

the actual physical record in order to make use of the business records hearsay 

exception. Under this view, “record,” as used in rule 5.803(6), refers to what you 
38

are bringing to the courtroom, not merely what you are proving up. But there is 

authority to the contrary:

Nothing in Federal Rule of Evidence 803(6) suggests the hearsay 

exception applies to statements made in business records only if the 

records have been separately admitted into evidence. If a proper 

foundation has been provided to show that a business’s 

record-keeping practices are sufficiently reliable under Rule 803(6), 

statements from the business’s records are not inadmissible as 

hearsay—regardless of whether the records are separately admitted 

into evidence. If, however, a witness testifies about the contents of 

documents that have not been separately admitted into evidence, 

that testimony may be excluded under Federal Rule of Evidence 

1002, provided that an exception to the so-called ‘best-evidence rule’ 

does not apply.

In re Lynch, 755 F. App’x 920, 924 n.5 (11th Cir. 2018) (per curiam) (finding that 

the appellants’ hearsay objections were properly overruled and that the 

appellants did not preserve an objection based on the best evidence rule). 

Regardless of nomenclature, though, no such objection is before us. 

Nowhere does Jackson raise the concept that now serves as the basis for his new 

trial. Jackson says, “Peterson’s testimony about information contained in 

Jackson’s Broadlawns medical records is black-letter hearsay.” But as Jackson’s 

citation to Madison and his briefing make clear, his “black-letter hearsay” 

objection is to the introduction of information from the medical records without 

adequate foundation, not that the information came in through Peterson’s 

testimony rather than the records themselves. Jackson criticizes the State for 

“eliciting hearsay evidence from Jackson’s Broadlawns records.” (Emphasis 

added.)

In the reply brief, after the State invokes Iowa Rule of Evidence 5.803(6), 

Jackson goes on in the same vein: “[M]edical records are admissible under Rule 

5.803(6) only upon proper foundation.” And: “There was no testimony from 

anyone with knowledge of how Broadlawns generates and maintains its records.” 
39

Jackson makes no issue out of the State’s use of testimony in lieu of introducing 

the records themselves.

It should be no surprise that the court of appeals panel, with over thirty 

years of combined appellate experience, concluded that Peterson’s testimony was 

admissible under rule 5.803(6) without even considering the possibility that the 

records themselves had to be introduced. No one had argued that the actual 

documents needed to be put in evidence. 

Even at the further review stage, with the benefit of the court of appeals 

decision, Jackson did not complain about the substitution of testimony for the 

records themselves. Rather, he reiterated that foundation was not established for 

the admission of the medical records. As he put it, quoting an unpublished 

decision out of the court of appeals, “Without the required foundation, the 

[testimony] did not qualify for the business-records exception.” State v. Fiems, 

No. 18–2241, 2020 WL 1879700, at *4 (Iowa Ct. App. Apr. 15, 2020).

By not raising any objection to Peterson’s testimony as a way of proving 

the contents of the medical records, Jackson waived the point. See Ruiz v. State, 

912 N.W.2d 435, 441 (Iowa 2018) (“The doctrine of waiver applies to issues not 

asserted on appeal . . . .”); see also State v. Torres, 989 N.W.2d 121, 130 (Iowa 

2023) (McDonald, J., concurring specially) (“To resolve this appeal, we need only 

address the issues actually presented.”). 

I am also not surprised that Jackson waived any complaint on appeal since 

the matter was not explored below. Before Peterson testified, there was a 

discussion outside the presence of the jury that went on for about seven pages 

of transcript. Most of the discussion focused on whether Jackson had waived the 

physician–patient privilege. Although Jackson’s counsel used the terms 

“hearsay” and “best evidence,” which is probably sufficient to preserve error, 

counsel never actually made the point that the records needed to be introduced 
40

instead of having Peterson testify about them. Had counsel made that point, it 

might have been possible to present the records themselves, which were in 

electronic form according to Peterson. Although I am not certain, it appears to 

me that the prosecutor was simply being cautious when she developed a plan to 

use Peterson’s testimony instead of actual records because she did not want to 

look at the records herself when there was a medical privilege issue that had not 

yet been resolved by the court.

Under these circumstances, I do not believe a new trial is warranted.

For the foregoing reasons, I dissent in part and would affirm all of 

Jackson’s convictions and his sentence.

Christensen, C.J., and Waterman, J., join this concurrence in part and 

dissent in part.