IN THE SUPREME COURT OF IOWA

No. 13–1202

Filed March 4, 2016

Amended May 5, 2016

STATE OF IOWA,

Appellee,

vs.

TRENT D. SMITH,

Appellant.

On review from the Iowa Court of Appeals. 

Appeal from the Iowa District Court for Black Hawk County, 

Jeffrey L. Harris, Judge. 

Defendant appeals from conviction for domestic abuse assault 

causing bodily injury. DECISION OF COURT OF APPEALS AFFIRMED 

IN PART AND VACATED IN PART; DISTRICT COURT JUDGMENT 

REVERSED AND REMANDED. 

Mark C. Smith, State Appellate Defender, and Melinda J. Nye, 

Assistant Appellate Defender, for appellant. 

Thomas J. Miller, Attorney General, Tyler Buller and Jean C. 

Pettinger, Assistant Attorneys General, Thomas J. Ferguson, County 

Attorney, and Jeremy Westendorf, Assistant County Attorney, for 

appellee. 
2

CADY, Chief Justice. 

In this appeal from a conviction for domestic abuse assault, we 

consider whether hearsay statements made to an emergency room nurse 

and doctor by a victim that identified the perpetrator of the attack were 

admissible under Iowa Rule of Evidence 5.803(4) as statements made for 

purposes of medical diagnosis or treatment. The court of appeals found 

the hearsay statements were properly admitted at the trial. On our 

review, we conclude there was insufficient foundation to admit the 

statements under rule 5.803(4). We affirm the decision of the court of 

appeals in part and vacate in part, reverse the decision of the district 

court, and remand for further proceedings. 

I. Background Facts and Proceedings. 

On June 9, 2012, at 1:03 a.m., the Black Hawk County emergency 

call center received a 911 call from M.D. She gave her address and said,

“Just get here, thank you, please!” A short time later, M.D.’s mother 

called the center on a nonemergency line. She told the phone operator 

that M.D. asked her to call the police to report that Trent Smith had 

threatened M.D. and that M.D. was afraid of him. 

Two officers were dispatched to M.D.’s residence. They found M.D.

sitting in a car outside the residence with her five-year-old daughter and 

a dog. The officers checked the residence for intruders and began their 

investigation by interviewing M.D. 

M.D. told the officers she had been upstairs and after hearing a 

sound was “hit” by something when going downstairs in the dark to 

investigate. She also said she lost consciousness after she was kicked in 

the head. She told the officers she believed the assailant had entered her 

residence through a locked door. M.D. eventually identified her assailant 

as “Trent Daniel,” whom dispatch officers later identified as Trent Smith. 
3

M.D. said Smith did not live at her residence but had been abusing her 

for ten years. She mentioned one prior assault when Smith beat her 

after he was released from jail following an arrest for domestic abuse. 

The officers took M.D. to the emergency room of a local hospital 

around 2:40 a.m. She was treated by a doctor and a nurse for her 

injuries. The doctor found M.D. to be “in a moderate amount of distress” 

and “extremely shaken up.” The nurse asked M.D. to explain what had 

happened to her. M.D. responded that she was “assaulted by her baby’s 

daddy around midnight.” She told the nurse that she had been kicked in 

the head and right arm, and she felt that her front teeth were loose. The 

nurse also pursued several standard screening questions at some point 

during the evening. Three questions pertained to domestic abuse. In 

response to these questions, M.D. indicated she did “feel afraid 

of/threatened by someone close to me.” She also responded she had 

“been hurt by someone.” She further agreed that “someone is taking 

advantage of [her].” 

In response to an inquiry by the doctor about how she sustained 

her injuries, M.D. said she had been assaulted by her child’s father. 

However, the doctor did not make any domestic abuse diagnosis or 

render any treatment for emotional or psychological injuries based on the 

identity of the perpetrator. The identity of the assailant or the effects of 

domestic abuse were not mentioned as a part of any treatment or 

diagnosis. The treatment consisted of radiology testing and other 

medical care to those areas of the body that had sustained physical 

injury. The diagnosis by the doctor pertained solely to the physical 

injuries sustained by M.D. It was limited to a closed head injury, 

cervical strain, facial contusion, and arm contusions. 
4

M.D. was released from the hospital around 5 a.m. She was 

prescribed pain and antianxiety medications. The officers took her to the 

law enforcement center to obtain a written statement. An officer wrote a

statement based on M.D.’s statements earlier in the night, but M.D.

refused to acknowledge it with her signature. 

Smith was subsequently charged with domestic abuse assault with 

intent to cause serious injury and domestic abuse assault causing bodily 

injury, both in violation of Iowa Code section 708.2A(2) (2011). At a 

pretrial hearing, the State informed the district court that M.D. intended 

to recant her statements identifying Smith as her assailant. The State 

further informed the court it intended to prove Smith was the assailant 

through the statements made by M.D. to the officers and medical 

personnel. In particular, the State indicated they would offer M.D.’s 

statements of identification made to the emergency room nurse and 

doctor under the medical treatment and diagnosis exception to the rule 

against hearsay. In response, Smith claimed the statements were not 

part of any medical diagnosis or treatment. The district court ultimately

determined the identification statements were admissible at trial under 

the medical treatment and diagnosis exception to the rule against 

hearsay. It also determined M.D.’s statements to police were admissible 

at trial under the excited-utterance exception to the rule against hearsay. 

The State never argued the statements to the nurse and doctor were also 

admissible as excited utterances, and the district court did not rely on 

the excited-utterance exception in admitting them.

The case proceeded to trial. Law enforcement officers and medical 

personnel at the hospital testified at trial for the State, as well as a 

domestic abuse expert. The officers and medical providers recalled the 

statements M.D. made to them the night of the incident that identified
5

Smith as her assailant. There was no testimony that M.D. was told how 

the questions related to her treatment or diagnosis, and there was no 

testimony how they were used or needed by medical providers in her 

treatment or diagnosis. The domestic abuse expert explained the 

dynamics of domestic abuse, including the control exercised by the 

perpetrator. M.D. testified for Smith at trial. She said she was injured 

when she fell from a trampoline after drinking in excess. 

The jury found Smith guilty of domestic abuse assault and 

domestic abuse assault causing bodily injury. Following sentencing, 

Smith appealed. He claimed the district court erred in admitting the 

hearsay statements made to police and medical personnel. He also 

claimed the district court erred in failing to merge the two convictions for 

purposes of sentencing. 

We transferred the case to the court of appeals. It found the 

district court erred by admitting M.D.’s statements to police as excited 

utterances. However, it found the district court did not err in admitting 

M.D.’s statements made to the nurse and doctor as statements for 

purposes of medical diagnosis or treatment. As a result, the court of 

appeals found Smith was not prejudiced by the admission of the hearsay 

statements to police. It merged the convictions and affirmed the 

judgment and sentence for domestic abuse assault causing bodily injury. 

Smith sought, and we granted, further review. The primary claim 

asserted by Smith is the statements of identity made to the doctor and 

nurse were inadmissible under the medical treatment and diagnosis 

exception. The State did not seek further review from the decision by the 

court of appeals that the statements made to police were not admissible 

as excited utterances. Accordingly, that decision stands as the final 

determination on that issue. See State v. Guerrero Cordero, 861 N.W.2d 
6

253, 258 (Iowa 2015) (addressing on further review only one of four 

issues raised on appeal). 

II. Scope of Review. 

Although we normally review evidence-admission decisions by the 

district court for an abuse of discretion, we review hearsay claims for 

correction of errors at law. State v. Paredes, 775 N.W.2d 554, 560 (Iowa 

2009). “[T]he question whether a particular statement constitutes 

hearsay presents a legal issue,” leaving the trial court no discretion on 

whether to admit or deny admission of the statement. State v. Dullard, 

668 N.W.2d 585, 589 (Iowa 2003). 

With respect to the issue now raised on further review involving 

the district court’s decision to admit at trial the statements of identity 

made to the medical providers, we recognize we may affirm a ruling on 

the admission of evidence by using a different rationale than relied on by 

the district court. See DeVoss v. State, 648 N.W.2d 56, 62 (Iowa 2002). 

However, the rule described in DeVoss is discretionary, and we must be 

careful not to exercise our discretion to decide an issue concerning the 

admissibility of evidence on an alternative ground when the parties have 

not had an opportunity to properly develop or challenge the foundation 

for the evidence. 

III. Admission of Statements Identifying Perpetrator. 

“ ‘Hearsay’ is a statement, other than one made by the declarant 

while testifying at the trial or hearing, offered in evidence to prove the 

truth of the matter asserted.” Iowa R. Evid. 5.801(c). Hearsay is not 

admissible at trial subject to certain exceptions and exclusions. See id.

r. 5.802. 

The statements at issue in this case—third-party accounts of 

identification statements made by M.D.—are hearsay. The question is 
7

whether they are admissible under an exception to the rule against 

hearsay. 

The general rationale for the rule against hearsay is that out-ofcourt statements are inherently unreliable because false perception, 

memory, or narration of the declarant cannot be addressed through the 

admission of an oath or exposed through cross-examination of the 

declarant. See 5 Jack B. Weinstein & Margaret A. Berger, Weinstein’s 

Federal Evidence § 802.02[3], at 802-6 to -7 (Mark S. Brodin 2d ed. 

2015) [hereinafter Weinstein]. Thus, the exceptions to the rule against 

hearsay generally overcome this rationale through the identification of 

circumstances surrounding the issuance of the statement that 

demonstrate its reliability and necessity. See id. § 802.03[3] [a], at 802-

8. 

One exception to the rule against hearsay relates to statements 

made for the purposes of medical diagnosis and treatment. Iowa R. Evid. 

5.803(4). This exception applies to

[s]tatements made for purposes of medical diagnosis or 

treatment and describing 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. The rationale for the exception is that statements made by a patient 

to a doctor for purposes of medical diagnosis or treatment are “likely to 

be reliable because the patient has a selfish motive to be truthful.” 

Weinstein § 803.06[1], at 803-41 to -42; see 7 Laurie Kratky Doré, Iowa 

Practice Series: Evidence § 5.803:4, at 951–52 (2015–2016 ed. 2015)

[hereinafter Doré]. This motive exists because the effectiveness of the 

medical treatment rests on the accuracy of the information imparted to 

the doctor. Weinstein § 803.06[1], at 803-41 to -42. A patient 
8

understands that a false statement in a diagnostic context could result in 

misdiagnosis. State v. Tornquist, 600 N.W.2d 301, 304 (Iowa 1999),

overruled on other grounds by State v. DeCamp, 622 N.W.2d 290 (Iowa 

2001). Thus, the circumstances of statements made for diagnosis and 

treatment provide “special guarantees of credibility” and justify the 

exception to the rule against hearsay. State v. Hildreth, 582 N.W.2d 167, 

169 (Iowa 1998). 

The medical diagnosis or treatment exception imposes two 

requirements. First, the exception applies to statements “made for 

purposes of medical diagnosis or treatment.” 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. Thus, the first requirement is 

directed at the purpose and motive of the statement, and the second 

requirement is directed at the content or description of the statement. 

Yet as to both requirements, the statements must also “be reasonably 

pertinent to diagnosis or treatment.” Doré § 5.803:4, at 952. These 

requirements track with the two-part test we adopted in State v. Tracy for 

establishing the admission of hearsay statements identifying a child 

abuser under the exception for medical diagnosis and treatment. 482 

N.W.2d 675, 681 (Iowa 1992) (“[F]irst[,] the declarant’s motive in making 

the statement must be consistent with the purposes of promoting 

treatment; and second, the content of the statement must be such as is 

reasonably relied on by a physician in treatment or diagnosis.” (quoting 

United States v. Renville, 779 F.2d 430, 436 (8th Cir. 1985))). 

The fighting issue in this case is whether the portion of the 

statement made to a doctor or nurse that identifies the person who 
9

caused or was the source of the injury is reasonably pertinent to 

diagnosis or treatment. This is a question that can be vexing for judges 

and lawyers. Normally, the identity of the perpetrator of physical injuries 

is not understood to be necessary information for effective medical 

treatment. United States v. Joe, 8 F.3d 1488, 1494 (10th Cir. 1993). 

Thus, these statements generally lack the inherent reliability of 

statements by patients to doctors for medical diagnosis or treatment. 

Colvard v. Commonwealth, 309 S.W.3d 239, 245–46 (Ky. 2010) (finding 

no inherent trustworthiness in identification statement not arising from a 

desire for effective treatment). When the identity of the perpetrator of an 

injury is not necessary information for effective medical treatment, a 

declarant could remain motivated to truthfully describe the cause of 

injuries while being motivated to suppress or twist the identity of the 

perpetrator towards their own ends. See State v. Long, 628 N.W.2d 440, 

444 (Iowa 2001) (noting ulterior motives aside from treatment may affect 

statements of causation made to medical providers). In other words, selfmotivation to be truthful that supports the admission of statements 

under the exception may be absent when the identity of the perpetrator

is not necessary or pertinent to the medical diagnosis or treatment. See 

id. Accordingly, each assertion sought to be admitted that is contained 

within a broader statement made to medical providers must meet the 

requirements of the exception to be admissible. 

We have identified some circumstances when statements that 

identify perpetrators are admissible under Iowa Rule of Evidence 

5.803(4). One circumstance involves the identity of perpetrators of child 

abuse. See Tracy, 482 N.W.2d at 681–82. When the “alleged abuser is a 

member of the victim’s immediate household, statements regarding the 

abuser’s identity are reasonably relied on by a physician in treatment or 
10

diagnosis.” Id. at 681. The emotional and psychological injuries of such 

abuse are treated by the doctor along with the physical injury. Id. The 

doctor is also often concerned about the possibility of recurrent abuse. 

Id. In Tracy, the doctor followed a standard dialogue for purposes of 

diagnosis and treatment, and the victim understood that the doctor 

needed truthful responses to provide treatment. Id. This circumstance 

is key to admitting statements of identity. The circumstances need to 

show that the victim’s statements are “not prompted by concerns 

extraneous to the patient’s physical or emotional problem.” Hildreth, 582 

N.W.2d at 169–70. 

The State argues that cases of domestic abuse fall within the same 

rule that commonly allows statements of the identity of perpetrators in 

cases of child abuse to be admitted. It argues the circumstances of this 

case fit within the reasoning behind the child-abuse exception because 

they do not show M.D. was motivated to be untruthful when she 

identified Smith as the assailant. 

The State’s overarching argument suggests that a categorical rule 

has emerged from rule 5.803(4) that admits statements of identity made 

to medical personnel by victims of child abuse and that should also 

apply to victims of domestic abuse. Yet, no such categorical rule for 

victims of child abuse has been recognized. While it is common for 

statements of identity made by victims of child abuse to be admitted 

under rule 5.803(4), the statements are not admitted simply because 

they fall within a category of statements made to doctors or medical 

personnel by victims of abuse. Instead, these statements are admitted 

only when there is evidence that the statements of identity were made by 

a child-abuse victim for purposes of diagnosis or treatment by a doctor or

medical provider and the identity was pertinent to the diagnosis or 
11

treatment. See State v. Dudley, 856 N.W.2d 668, 676 (Iowa 2014) (“The 

child must make the statements to a trained professional for the 

purposes of diagnosis or treatment to be admissible under rule 

5.803(4).”); Doré § 5.803:4, at 957–58 & nn.22–23 (collecting cases and 

contrasting how courts apply the rule); see also State v. Neitzel, 801 

N.W.2d 612, 621–22 (Iowa Ct. App. 2011) (discussing the steps taken by 

healthcare professionals to ensure truthfulness and the need to assess 

safety risks and the child’s need for further counseling). Eliciting the 

identity of a perpetrator of child abuse can be a normal aspect of medical 

treatment and diagnosis for child abuse victims; however, the value of 

that information is established by the foundational testimony of the 

doctors and medical providers in each case, and that testimony explains 

the pertinence of the perpetrator’s identity to the diagnosis and 

treatment of the victim in the uinique circumstances of each case. See, 

e.g., Hildreth, 582 N.W.2d at 169–70 (setting foundation for social 

workers’ diagnosis of child’s emotional disturbance resulting from sexual 

abuse). The need to establish foundation for the admission of evidence 

under rule 5.803(4) is compatible with the standard approach to the 

admission of evidence under most other rules of evidence. In other 

words, proper foundation must normally be established before evidence 

may be admitted. See State v. Tompkins, 859 N.W.2d 631, 639 (Iowa 

2015) (requiring the State to lay a proper foundation before finding 

hearsay statements identifying a domestic abuse assailant and his 

actions admissible). There is no rule that provides a categorical

exception for victims of child abuse or domestic abuse. 

The profound and serious problem of domestic abuse in this nation 

and this state does not escape us in our analysis of this case. These 

problems are significant for victims of domestic abuse and the children 
12

who have suffered by witnessing the abuse. The consequences to these 

victims and society as a whole are diverse and immense. These are 

problems and consequences this court has been addressing for decades. 

See generally Final Report of the Supreme Court Task Force on Courts’ and 

Communities’ Response to Domestic Abuse (1994) (compiling statistics on 

the incidence of domestic abuse in Iowa, identifying the courts’ role, and 

formulating recommendations to address the problem from the judicial 

standpoint). We are also aware that the underlying dynamics of 

domestic abuse can create many obstacles in the criminal prosecution of 

perpetrators. See Laurie S. Kohn, The Justice System and Domestic 

Violence: Engaging the Case but Divorcing the Victim, 32 N.Y.U. Rev. L. & 

Soc. Change 191, 200–06 (2008) (discussing the influence of outside 

factors on victims’ behavior both before and after reporting abuse and 

affecting their cooperation with the justice system). These complex 

dynamics can lead many victims to refrain from reporting abuse and 

then further lead to the recantation of statements of identity prior to 

trial. See id. at 203–05 (noting victims may ask to drop the criminal 

case, refuse to testify, recant, or downplay their risks); Jennifer L. 

Truman & Rachel E. Morgan, U.S. Dep’t of Justice, Nonfatal Domestic 

Violence, 2003–2012, at 9 & tbl. 8, http://www.bjs.gov/content/pub/

pdf/ndv0312.pdf (revealing only around fifty-five percent of domestic 

violence is reported to police). Nevertheless, our role in reviewing the 

admission of the hearsay statements at trial in this case is not to inject 

this policy into the analysis to create a new rule of evidence. Our 

authority to establish rules to govern the trial of a case exists 

independent of our authority to decide issues presented to us on appeal 

in cases. Today, we only address the issue of admission of statements of 
13

identity through our existing rule of evidence. Our role is to interpret the 

rule as it is written and apply the hearsay exception as it exists. 

Moreover, any categorical evidentiary rule must carefully consider 

the competing interests at stake. These interests include those found in 

the constitutional right of people accused of crimes to be confronted by 

their accusers. See, e.g., State v. Bentley, 739 N.W.2d 296, 300–01 (Iowa 

2007) (weighing accused’s confrontation right against the interests of a 

child abuse victim). They are also found in the concept of fundamental 

fairness. See Iowa R. Evid. 5.102. The sheer complexity of domestic 

abuse would need to be considered, including both the interests of the 

victim and the rights of the accused. It has been observed that “there is 

neither a ‘typical’ victim of domestic violence, nor ‘typical’ responses, nor 

‘typical’ circumstances in which such violence occurs.” Jane C. Murphy 

& Robert Rubinson, Domestic Violence and Mediation: Responding to the 

Challenges of Crafting Effective Screens, 39 Fam. L.Q. 53, 58 (2005) 

(footnotes omitted). Thus, any categorical rule cannot be adopted that 

would “ignore[] variables such as the seriousness of the assault, the 

frequency of the abuse against the victim, the type of domestic 

relationship, or the presence or absence of emotional or psychological 

harm.” State v. Robinson, 718 N.W.2d 400, 407 (Minn. 2006) (refusing to 

adopt a categorical exception to rule 803(4) in domestic violence cases). 

We understand how the identity of an abuser could be pertinent to 

the treatment of a domestic abuse victim by a doctor. Domestic abuse 

victims suffer from far more than physical injuries. Emotional and 

psychological injuries are also inflicted with an assault, and it is 

understandable how the depth and breadth of those injuries would vary 

depending on the identity of the abuser. As a result, we see how 

complete medical treatment could normally include information on the 
14

identity of the abuser. Yet, until a categorical rule exists, this 

understanding must be supplied from the testimony of doctors in the 

form of foundation pursuant to the broad rule providing for the 

admission of hearsay statements for all types of medical treatment. See 

Joe, 8 F.3d at 1494 & n.6 (citing to doctor testimony that established

foundation despite finding there is general need for identity knowledge in 

domestic abuse cases).

In this light, we reject the argument by the State that statements of 

identity by victims of domestic abuse should be categorically admissible 

because such statements are now commonly admitted in cases of child 

abuse. Instead, we hold that in each case, the trial court must, as with 

other statements made during medical diagnosis and treatment, apply 

the test we adopted in Tracy to determine whether the statements made 

in that case should fall within this exception to the hearsay rule.1 482 

N.W.2d at 681. The State, as the proponent of the evidence, has the 

burden to show the statements fit within rule 5.803(4).2 Long, 628 

N.W.2d at 443. 

1Several other courts also examine whether criteria similar to our Tracy test 

have been met before admitting identity statements. E.g., United States v. Bercier, 506 

F.3d 625, 632 (8th Cir. 2007) (requiring foundation that the statements were essential 

to diagnosis and treatment in domestic sexual abuse case); Robinson, 718 N.W.2d at 

407 (holding domestic abuse victim’s identification of her assailant inadmissible 

without sufficient evidentiary foundation establishing the identity was reasonably 

pertinent to diagnosis or treatment); State v. Moen, 786 P.2d 111, 118–21 (Or. 1990) 

(en banc) (examining prior statements made concerning domestic abuse causing 

victim’s depression to determine whether they met the foundational criteria of 

pertinence to medical diagnosis in murder case); Oldman v. State, 998 P.2d 957, 961–62 

(Wyo. 2000) (utilizing the Renville criteria to determine the identity in a domestic abuse 

case was pertinent for treating bite marks for infectious condition). 

2We recognize that statements made to emergency personnel in order to obtain 

medical treatment can also fall within the excited-utterance exception to the hearsay 

rule. Iowa R. Evid. 5.803(2); State v. Harper, 770 N.W.2d 316, 319–20 (Iowa 2009) 

(finding no need to determine if the statements would fall within rule 5.803(4) by 

holding other exceptions applied). However, the State made no claim in the district 

court or its appeal that the excited-utterance rule should apply. 

 
15

The foundation required to admit a statement identifying a 

perpetrator of domestic abuse under rule 5.803(4) need not be elaborate. 

It establishes why the identity of the assailant is important in a domestic 

abuse case, as opposed to stranger assault, and what effect that identity 

has on diagnosis or treatment. It recognizes there is a difference between 

the need to know the cause or external source of the injuries—i.e., “what

happened”—and the need to know the identity of the person causing the 

injuries. See United States v. Iron Shell, 633 F.2d 77, 84 (8th Cir. 1980) 

(“It is important to note that the statements concern what happened 

rather than who assaulted her. The former in most cases is pertinent to 

diagnosis and treatment while the latter would seldom, if ever, be 

sufficiently related.”).3 It requires evidence that the identity of the 

perpetrator was reasonably pertinent to medical treatment or diagnosis. 

We now turn to the evidence in this case. 

The trial record in this case shows the nurse and the doctor only 

asked M.D. how she was injured, and their treatment efforts that 

followed only focused on the physical trauma to her head, arm, and 

hand. The nurse also asked three questions pertaining to domestic 

abuse in general pursuant to a broader screening protocol. However, the 

State offered no evidence that the protocol questions prompted any 

treatment of M.D. for her emotional or psychological response to the 

injuries or were asked in order to make a diagnosis relating specifically to 

domestic assault over other types of assault. In other words, the 

foundational evidence relating to her statements only pertained to the 

3The United States Court of Appeals for the Eighth Circuit found five years later 

that a child-abuse victim who lived in the same household with the abuser was 

sufficiently different to fall within the narrow seldom-sufficiently-related category left 

open by Iron Shell. Renville, 779 F.2d at 436. 

 
16

treatment she received for her physical injuries, not treatment she might 

have needed for her emotional, psychological, or other injuries as a result 

of the domestic violence.

M.D. was prescribed antianxiety medication prior to her discharge, 

but there was no evidence that the medication pertained to treatment of 

domestic abuse rather than the same anxiety as might be felt in a 

stranger-assault situation. It would be pure speculation to conclude the 

antianxiety medication related to the identity of the perpetrator. The rule 

requires that the connection between the statement and the treatment be 

“reasonable.” Iowa R. Evid. 5.803(4).

Importantly, there was no evidence to suggest M.D. believed the 

identity of the perpetrator was reasonably pertinent to her treatment or 

diagnosis. There was no evidence the nurse or doctor told M.D. the 

identity of the perpetrator was important to the treatment or diagnosis of 

her injuries. There was no evidence the nurse or doctor used the identity 

of the perpetrator to treat or diagnosis M.D.’s injuries. In fact, there was 

nothing from the circumstances at the hospital to reasonably indicate 

M.D.’s treatment or diagnosis would have been different if she had not 

mentioned the identity of her perpetrator in describing how she was 

injured.

In short, the State presented insufficient evidence that the identity 

of the assailant was reasonably pertinent to M.D.’s diagnosis or 

treatment. Consequently, the circumstances mandated by the exception 

to show M.D. was self-motivated to truthfully describe her assailant were 

not established. Without this foundation, the trial court erred in 

admitting the portion of the statement that identified Smith as the 

assailant. 
17

We acknowledge that the general circumstances presented at trial 

do not suggest a motivation by M.D. to be untruthful in her identification 

of Smith as her assailant to the emergency room nurse and doctor. Her 

statements of identity were not prompted by any cues asking for the 

identity of the perpetrator, and she only conveyed Smith’s identity as 

part of the description of how she was injured.4 Yet the exception does 

not seek to use the absence of a motive to be untruthful, but it requires 

evidence of a specific motivation to be truthful derived from its rationale. 

We are required to follow rule 5.803(4) as it is written. 

This conclusion does not mean the identity of a perpetrator of 

domestic abuse can never be admitted into evidence under rule 5.803(4). 

It only means that the State must introduce evidence to establish the 

necessary foundation regarding both the declarant’s motive in making 

the statement and the pertinence of the identification in diagnosis or 

treatment. This foundation requires evidence that a statement of identity 

was made for the purpose of medical diagnosis or treatment and the 

identity was part of a medical history reasonably pertinent to diagnosis 

or treatment. 

IV. Conclusion. 

We conclude the trial court committed legal error by admitting the 

hearsay statements of M.D. through the testimony of the emergency 

room nurse and doctor without sufficient foundation. This error resulted 

in prejudice and requires a new trial. To be fair to both parties, we 

decline to consider for the first time on appeal whether the evidence 

4M.D. recanted not only the identity of an assailant, but even the existence of an 

assault causing her injuries when she testified in court. However, the treating nurse 

and physician both testified that M.D.’s injuries were consistent with the description of 

the assault that evening. 

 
18

would have been admissible under another exception to the rule against 

hearsay. Accordingly, we reverse the judgment and sentence of the 

district court and remand for a new trial. 

DECISION OF COURT OF APPEALS AFFIRMED IN PART AND 

VACATED IN PART; DISTRICT COURT JUDGMENT REVERSED AND 

REMANDED. 

All justices concur except Waterman, Mansfield, and Zager, JJ., 

who dissent. 
19

#13–1202, State v. Smith

WATERMAN, Justice (dissenting).

I respectfully dissent. I agree with the court of appeals that the 

district court properly allowed the emergency room physician and nurse 

to testify regarding the victim’s identification of Smith, her ex-boyfriend 

and the father of her child, as her attacker. That information was 

elicited pursuant to the hospital’s screening protocol to protect patients 

traumatized by suspected domestic abuse. As the medical community 

and many other courts have long recognized, identifying the abuser is a 

key component in treating the patient’s mental and physical injuries and 

ensuring the patient’s safety. The majority errs by holding the district 

court abused its discretion by admitting the testimony under Iowa Rule 

of Evidence 5.803(4) and misses the opportunity to adopt a categorical 

rule allowing medical treatment providers to testify regarding a patient’s 

identification of an intimate partner as the assailant. In my view, our 

court adopted a categorical rule in child abuse cases, and the rationale 

easily extends to adult domestic abuse. I would join the parade of courts 

adopting a categorical rule. Our application of this rule of evidence 

should evolve in response to the growing understanding and body of 

medical literature on intimate-partner violence. 

Moreover, even if I agreed with the majority that admission of this 

kind of evidence should occur only on a case-by-case basis, I would find 

the record here adequate to warrant its admission. The State in this 

case laid the requisite foundation for the admission of the evidence under 

rule 5.803(4). This case is emblematic of the recurring problem in 

domestic abuse cases—a victim who identifies the attacker while 

traumatized but then later, controlled by his or her abuser, changes his 

or her story or refuses to cooperate with the prosecution. I trust Iowa 
20

juries to find the truth. In this case, the jury disbelieved the victim’s trial 

testimony that her injuries resulted from falling off a trampoline and 

believed what she told her treating physician and nurse the night of her 

attack. 

I would also affirm the district court ruling allowing the physician 

and nurse to testify as to the victim’s identification of her assailant on an 

alternative ground the majority understandably declines to reach—the 

excited-utterance exception to the hearsay rule. The victim was still 

reeling from the assault when she spontaneously identified Smith at the 

hospital simply when asked what happened to her. We may affirm an 

evidentiary ruling on any valid alternative ground supported by the 

record. See DeVoss v. State, 648 N.W.2d 56, 62 (Iowa 2002). The State, 

however, did not raise that ground in district court or brief it on appeal, 

and the court of appeals did not reach it as to the emergency room 

personnel. The majority appropriately chooses to defer deciding the 

issue under these circumstances, and nothing in today’s opinion 

precludes the State from relying on the excited-utterance exception in 

the second trial. 

I. Additional Facts. 

The majority’s recitation of the facts is truncated. To put the 

issues in better context, I will recapitulate what happened to M.D. When 

police officers responding to her 911 call arrived at her home at 1 a.m., 

M.D., age twenty-nine, was sitting in her car with her five-year-old 

daughter and dog. M.D. was crying, upset, tense, and scared, with 

visible injuries—a swelling in her arm and around one eye, and scratches 

on her shoulder and knees. She initially told police an intruder had 

jimmied the side door lock and attacked her. She said he called her a 

“dirty whore,” punched her, knocked her to the floor, and kicked the 
21

back of her head repeatedly. She told officers she had blacked out 

during the attack and thought her arm was broken. At first she claimed 

she did not know her assailant. The officers were skeptical because they 

had previously been summoned to M.D.’s home over an altercation with 

Trent Daniel Smith, the father of her child.5 The police persisted in 

questioning M.D. and urged her to be honest with them. She indicated 

she was afraid of her attacker and told police, “[Y]ou guys can’t protect 

me forever.” She then said “Trent Daniel” attacked her. Under further 

questioning, M.D., who seemed scared, gave Smith’s full name.

The police officers gave M.D. a ride to the emergency room at Allen 

Memorial Hospital for treatment. When she arrived, she was “extremely 

shaken up.” Nurse Trisha Knipper asked M.D. what happened and wrote 

down that M.D. said she “was assaulted by her baby’s daddy around 

midnight.” Knipper, pursuant to the hospital’s protocol, asked M.D. 

screening questions that are asked of every patient who presents with a 

traumatic injury. M.D. answered that “there was domestic violence going 

on,” “she was afraid of or threatened by someone close to her,” “she had 

been physically hurt by her baby’s dad,” and “she felt as if someone was 

taking advantage of her.” 

Approximately eleven minutes after being admitted to the 

emergency room, M.D. spoke with Dr. Robert Mott. Dr. Mott asked what 

happened, and she replied she “was assaulted by the father of her child.” 

She said she was knocked to the ground and kicked in the head and face 

multiple times. Dr. Mott noted that she was in a lot of pain and her arm 

5Smith was the father of M.D.’s daughter. M.D. and Smith also had a son 

together, but the son died. 

 
22

was very tender. No bone fractures were found. M.D. was given 

antianxiety medication and discharged at 5 a.m. 

At trial eleven months later, M.D. changed her story to claim her 

injuries resulted from falling off a trampoline. The jury heard the 

testimony of the emergency room nurse and physician and police that 

M.D. had identified Smith as her attacker. The jury convicted Smith of 

domestic abuse assault and domestic abuse causing bodily injury. The 

court of appeals affirmed his convictions, concluding the district court 

properly admitted the testimony of the emergency room physician and 

nurse under Iowa Rule of Evidence 5.803(4) and that it was harmless 

error to admit the police officer’s testimony of M.D.’s identification of 

Smith under the excited-utterance exception, rule 5.803(2). I would 

affirm the decisions of the district court and court of appeals.

II. The Medical Diagnosis and Treatment Exception. 

The fighting issue is whether the patient’s identification of her 

assailant is admissible under the hearsay exception for 

[s]tatements made for purposes of medical diagnosis or 

treatment and describing 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. 

Iowa R. Evid. 5.803(4). In State v. Tracy, we adopted the Renville twopart test to establish the admissibility of statements under this 

exception: 

[F]irst[,] the declarant’s motive in making the statement 

must be consistent with the purposes of promoting 

treatment; and second, the content of the statement must be 

such as is reasonably relied on by a physician in treatment 

or diagnosis. 

482 N.W.2d 675, 681 (Iowa 1992) (quoting United States v. Renville, 779 

F.2d 430, 436 (8th Cir. 1985)). In Renville, the United States Court of 
23

Appeals for the Eighth Circuit applied that test to affirm a trial court 

ruling that admitted a treating physician’s testimony regarding the child 

abuse victim’s identification of her abuser during a medical examination. 

779 F.2d at 438–39. As I show below, our decisions in child abuse cases 

reach the same conclusion and demonstrate that a domestic abuse 

victim’s identification of his or her attacker is admissible under this test. 

A. M.D.’s Statement Was Reasonably Pertinent to Medical 

Diagnosis or Treatment. The emergency room nurse, Knipper, testified 

that M.D., like every patient admitted into the emergency room, was 

asked screening questions under the hospital’s standard protocol. These 

questions covered topics including domestic violence, suicide, and 

workplace injuries. M.D.’s responses indicated she had experienced 

domestic violence. Each response was noted in M.D.’s chart. Knipper 

testified that she is required to “document complaints and treatment and 

diagnoses” on a chart for every patient that enters the hospital. The 

chart is maintained as a reference “for continued care” or “for any other 

needs that come about.” Knipper’s testimony shows that the 

documented responses to these standardized questions are used by the 

medical community in crafting a treatment plan and diagnosing the 

patient. M.D. replied to the standard questions by identifying Smith. 

M.D.’s statement was responsive to the questions being asked, and that 

information can be useful for diagnosis or treatment. 

Dr. Mott’s testimony showed that he considers the patient’s version 

of what happened to be highly relevant to treatment. Dr. Mott testified 

regarding how he approaches new patients in the emergency room: 

Q. And do you try to find out from the patient what 

had happened? A. Absolutely. 

Q. Is that necessary for treating the patient? A. That 

is key. 
24

When M.D. entered the emergency room, Dr. Mott followed his protocol 

to determine how to proceed with treatment: 

Q. And did you speak with [M.D.] about what had 

happened? A. I did. 

Q. And what did she say occurred? 

MS. LAVERTY: Objection. 

THE COURT: Same ruling. Overruled. 

Q. You may answer. A. Okay. She said that she was 

assaulted by the father of her child, was pretty much the 

first thing that she told me. 

Q. And did she explain to you how she was assaulted? 

A. She stated that she was knocked to the ground. And 

then once she was on the ground, then she was kicked in 

the head and the face multiple times. 

His medical testimony showed that M.D.’s explanation of why she came 

to the emergency room was key to determine a proper course of 

treatment. See Vasconez v. Mills, 651 N.W.2d 48, 56 (Iowa 2002) (noting 

a doctor “who is called to treat and actually treats the patient” may 

testify under the hearsay exception because there is an increased 

“probability that the patient will not falsify in statements made to his 

physician at a time when he is expecting and hoping to receive from him 

medical aid and benefit.” (quoting Devore v. Schaffer, 245 Iowa 1017, 

1021, 65 N.W.2d 553, 555 (1954))). 

M.D. consistently identified Smith as her attacker to medical 

personnel that night. That she recanted nearly a year later at trial does 

not cast doubt on her motives when seeking treatment the night of her 

attack. See Douglas E. Beloof & Joel Shapiro, Let the Truth Be Told: 

Proposed Hearsay Exceptions to Admit Domestic Violence Victims’ Out of 

Court Statements as Substantive Evidence, 11 Colum. J. Gender & L. 1, 

3–4 (2002) (listing reasons why victims recant). The rate of recantation 

among domestic violence victims has been estimated between eighty and 

ninety percent. Id.; Lisa Marie De Sanctis, Bridging the Gap Between the 
25

Rules of Evidence and Justice for Victims of Domestic Violence, 8 Yale J.L. 

& Feminism 359, 367 (1996); see also People v. Brown, 94 P.3d 574, 576 

(Cal. 2004) (approving the use of expert testimony stating that “[a]bout 

80 to 85 percent of victims ‘actually recant at some point in the 

process’ ”); State v. Dority, 324 P.3d 1146, 1152 (Kan. Ct. App. 2014) 

(noting that a fact finder may use common knowledge that “victims of 

domestic violence often recant their initial statements to police” (quoting 

State v. Coppage, 124 P.3d 511, 515 (Kan. Ct. App. 2005))). 

Dr. Mott and Knipper treated M.D. for her emotional or 

psychological response to the attack. She was prescribed antianxiety 

medication. The hospital’s screening questions do not exist in a vacuum. 

The questions about domestic abuse are asked for a reason—to allow the 

treating physicians and nurses to understand what happened and 

properly conduct follow-up treatment as necessary. In any event, rule 

5.803(4) does not condition admissibility on a showing that the patient’s 

statements given for medical treatment and diagnosis were actually used 

for treatment. See State v. Hildreth, 582 N.W.2d 167, 170 (Iowa 1998) 

(holding medical diagnosis and treatment hearsay exception applies to 

child sex abuse cases because “the identity of the abuser is a matter that 

may assist in diagnosis or treatment of an emotional or psychological 

injury” (emphasis added)). The context in which the identification is 

made is what matters, not what the treating physician and nurse did 

with that information. 

For these reasons, M.D.’s statements were admissible under the 

medical diagnosis and treatment hearsay exception. 

B. We Should Adopt a Categorical Rule. A categorical rule 

would be a logical extension of our jurisprudence regarding this hearsay 

exception’s application to child abuse cases. Our precedents recognize 
26

that a statement to a treating physician by a child identifying his or her 

abuser is admissible under rule 5.803(4). State v. Tornquist, 600 N.W.2d 

301, 306 (Iowa 1999) (holding a child’s “responses in a dialogue initiated 

for purposes of diagnosis or treatment” for child abuse “may assist in 

diagnosis or treatment”), overruled on other grounds by State v. DeCamp, 

622 N.W.2d 290, 293 (Iowa 2001); Hildreth, 582 N.W.2d at 170 

(“[A]scertaining the identity of the [child’s] abuser is a matter that may 

assist in diagnosis or treatment of an emotional or psychological 

injury.”); Tracy, 482 N.W.2d at 682 (“Because of the nature of child 

sexual abuse, the only direct witnesses to the crime will often be the 

perpetrator and the victim. Consequently, much of the State’s proof will 

necessarily have to be admissible hearsay statements made by the victim 

to relatives and medical personnel.”); see also Renville, 779 F.2d at 436 

(“Statements by a child abuse victim to a physician during an 

examination that the abuser is a member of the victim’s immediate 

household are reasonably pertinent to treatment.”). 

In Tracy, we stressed that a child seeking medical treatment will 

generally lack an improper motive, and the identification of an abuser is 

reasonably pertinent to medical treatment. 482 N.W.2d at 681. In that 

case, a minor told her doctor during an examination that she had been 

sexually abused by her stepfather. Id. We concluded the first 

requirement is met when “the examining doctor emphasize[s] to the 

alleged victim the importance of truthful responses in providing 

treatment” and when the “child’s motive in making the statements [is] 

consistent with a normal patient/doctor dialogue.” Id. 

The second part of the Renville test for admissibility 

under rule 803(4) requires that the content of the statement 

be such as is reasonably relied on by a physician in 

treatment or diagnosis. Where the alleged abuser is a 

member of the victim’s immediate household, statements 
27

regarding the abuser’s identity are reasonably relied on by a 

physician in treatment or diagnosis. Since child abuse often 

involves more than physical injury, the physician must be 

attentive to treating the emotional and psychological injuries 

which accompany this offense. To adequately treat these 

emotional and psychological injuries, the physician will often 

times need to ascertain the identity of the abuser. 

Id. at 681 (emphasis added) (citations omitted). The same reasoning 

applies to adult domestic abuse victims. 

In Hildreth, A.E., a minor, made several comments that led her 

parents to suspect the child had been sexually abused by her 

babysitter’s son, Steven Hildreth. 582 N.W.2d at 168. A.E. was referred 

to a therapist, who interviewed A.E. about her recollections of the abuse 

and the identity of her abuser. Id. at 169. The trial court permitted the 

therapist to testify regarding A.E.’s identification of her abuser at trial. 

Id. In affirming the trial court ruling, we emphasized that “where a 

child’s statements are made during a dialogue with a health care 

professional and are not prompted by concerns extraneous to the 

patient’s physical or emotional problem, the first prong of the Renville 

test is satisfied.” Id. at 170. We held the second requirement was 

satisfied because “ascertaining the identity of the abuser is a matter that 

may assist in diagnosis or treatment of an emotional or psychological 

injury.” Id. 

The justifications expressed in Hildreth and Tracy for a physician 

treating child abuse parallel a physician treating adult domestic abuse. 

Regarding the first prong, a domestic violence victim has no motive to lie 

to a doctor or nurse. The identification of the abuser is “consistent with 

a normal patient/doctor dialogue” because standard screening questions 

elicit this information. See Tracy, 482 N.W.2d at 681. The second 

requirement is met because, as with child abuse, doctors must be 
28

attentive to treating the emotional and psychological injuries that 

accompany domestic violence.

The United States Court of Appeals for the Tenth Circuit 

recognized these similarities in United States v. Joe and explained why a 

categorical rule for adult domestic violence logically follows from child 

abuse jurisprudence:

[T]he identity of the abuser is reasonably pertinent to 

treatment in virtually every domestic sexual assault case, 

even those not involving children. All victims of domestic 

sexual abuse suffer emotional and psychological injuries, the 

exact nature and extent of which depend on the identity of 

the abuser. The physician generally must know who the 

abuser was in order to render proper treatment because the 

physician’s treatment will necessarily differ when the abuser 

is a member of the victim’s family or household. In the 

domestic sexual abuse case, for example, the treating 

physician may recommend special therapy or counseling and 

instruct the victim to remove herself from the dangerous 

environment by leaving the home and seeking shelter 

elsewhere. In short, the domestic sexual abuser’s identity is 

admissible under Rule 803(4) where the abuser has such an 

intimate relationship with the victim that the abuser’s 

identity becomes ‘reasonably pertinent’ to the victim’s proper 

treatment.

8 F.3d 1488, 1494–95 (10th Cir. 1993) (footnote omitted). I agree. 

We should adopt a categorical rule to allow healthcare providers to 

testify as to the adult domestic abuse victim’s identification of an 

intimate partner as the assailant. The Louisiana Supreme Court recently 

surveyed current medical literature and practices to adopt a categorical 

rule that

reflects the current integrated approach to the treatment of 

domestic violence cases in the medical community. See

American Medical Association Policy Statement on Family 

and Intimate Partner Violence H–515.965 Chicago: AMA 

(2014) (advocating that physicians: (a) “Routinely inquire 

about the family violence histories of their patients as this 

knowledge is essential for effective diagnosis and care;” and 

(e) “Screen patients for psychiatric sequelae of violence and 

make appropriate referrals for these conditions upon 

identifying a history of family or other interpersonal 
29

violence.”) (emphasis added); see also U.S. Dep’t of Health & 

Human Serv., Screening for Domestic Violence in Health 

Care Settings (August 2013), Office of the Assistant 

Secretary for Planning and Evaluation (“Screening and 

counseling for domestic violence was first institutionalized in 

1992 when the Joint Commission on the Accreditation of 

Hospitals and Health Care Organizations (JCAHO) mandated 

that emergency departments develop written protocols for 

identifying and treating survivors of domestic violence in 

order to receive hospital accreditation (Joint Commission, 

2009). Since then, many health associations have supported 

screening across health care specialties. The American 

Medical Association (AMA), American Congress of 

Obstetrician Gynecologists (ACOG), and the American 

Nurses Association (ANA) all recommend routine universal 

screening.”). 

State v. Koederitz, 166 So. 3d 981, 985–86 (La. 2015) (footnote omitted). 

Mandatory screening procedures, such as the one used in the 

emergency room in this case, recognize the harsh reality that many 

people are repeatedly victimized by the same person during the domestic 

abuse cycle. Approximately two-thirds of people—65.5% of women and 

66.2% of men—physically assaulted by an intimate partner are 

victimized multiple times by the same partner. See Patricia Tjanden & 

Nancy Thoennes, U.S. Dep’t of Justice, Extent, Nature, and Consequences 

of Intimate Partner Violence 39 (2000). Domestic violence survivors are 

often caught in cycles of violence that may persist for years. The average 

female domestic violence survivor reported the domestic violence cycle 

involving an intimate partner lasted over 4.5 years, whereas the average 

male domestic survivor’s cycle lasted 3.6 years. Id. at 39–40. In 

consideration of these sobering statistics, we should adopt a per se rule 

that the identification of the perpetrator of domestic violence is pertinent 

to medical diagnosis or treatment and admissible under rule 803(4). 

Other jurisdictions have reached this conclusion and adopted a 

categorical rule. See Joe, 8 F.3d at 1494–95; Moore v. City of Leeds, 1 

So. 3d 145, 150 (Ala. Crim. App. 2008) (“We believe that the rationale 
30

employed by the [Alabama] Supreme Court in [Ex parte C.L.Y., 928 So. 2d 

1069 (Ala. 2005), announcing a categorical rule to admit a child–patient’s 

identification of their abuser] would also apply to victims of domestic 

violence.”); Nash v. State, 754 N.E.2d 1021, 1025 (Ind. Ct. App. 2001) 

(“[I]n cases such as the present one where injury occurs as the result of 

domestic violence, which may alter the course of diagnosis and 

treatment, trial courts may properly exercise their discretion in admitting 

statements regarding identity of the perpetrator.”); Koederitz, 166 So. 3d 

at 985–86 (“[W]e see no principled basis for confining statements of fault 

under [the medical diagnosis and treatment exception] solely to cases 

involving domestic sexual assault, whether of adults or children, as 

opposed to other instances of physical assault and abuse taking place in 

a context that may be fairly described in terms of domestic violence.”); 

People v. Pham, 987 N.Y.S.2d 687, 690–91 (App. Div. 2014) (“Details of 

the abuse, even including the perpetrator’s identity, may be relevant to 

diagnosis and treatment when the assault occurs within a domestic 

violence relationship because the medical provider must consider the 

victim’s safety when creating a discharge plan and gauging the patient’s 

psychological needs.”); State v. Moen, 786 P.2d 111, 121 (Or. 1990) 

(en banc) (“Admissibility of statements of the type challenged here[—i.e., 

a domestic abuse victim identifying her abuser—]is not limited to cases 

involving child abuse.”); State v. Bong, No. 33000–1–III, 2015 WL 

3819223, at *5 (Wash. Ct. App. 2015) (“Although statements attributing 

fault are generally not relevant to diagnosis or treatment, this court has 

found statements attributing fault to an abuser in a domestic violence 

case are an exception because the identity of the abuser is pertinent and 

necessary to the victim’s treatment.”); State v. Moses, 119 P.3d 906, 911 

(Wash. Ct. App. 2005) (same); Oldman v. State, 998 P.2d 957, 961 (Wyo. 
31

2000) (“There is no logical reason for not applying [the sexual domestic 

abuse exception in Joe] to non-sexual, traumatic abuse within a family 

or household, since sexual abuse is simply a particular kind of physical 

abuse.”); Commonwealth v. O’Connor, 6 N. Mar. I. 125, 129 (N. Mar. I. 

2000) (“[I]n cases of domestic and child abuse . . . the identity of the 

abuser becomes ‘reasonably pertinent to diagnosis or treatment[,’] and a 

statement identifying the abuser is admissible under the medical hearsay 

exception.”). These decisions are persuasive and should be followed. 

The majority concludes there are too many variables in domestic 

violence cases to adopt a categorical rule, relying on State v. Robinson, 

without mentioning the Minnesota Supreme Court in that decision 

expressly left open the possibility it would adopt a categorical rule for 

domestic abuse cases in the future. 718 N.W.2d 400, 407 (Minn. 2006) 

(“We do not foreclose the possibility that we might in the future adopt a 

properly limited categorical rule of admissibility under the medical 

exception to hearsay for statements of identification by victims of 

domestic violence.”). 

The majority also refers to “the constitutional right of people 

accused of crimes to be confronted by their accusers,” citing for support 

State v. Bentley. 739 N.W.2d 296, 300–01 (Iowa 2007). Bentley is 

nothing like this case. There, the police investigating child abuse 

arranged a “forensic interview” of the ten-year-old victim who was told at 

the outset of her interview that “a police officer and a DHS representative 

were listening on the other side of the observation window.” Id. at 300. 

When the child asked to halt the interview, her interrogator “specifically 

implored [the victim] to continue because ‘it’s just really important the 

police know about everything that happened.’ ” Id. The interrogator 

during breaks consulted with the police officer about additional 
32

questions to ask. Id. By contrast, M.D. asked the police to take her to 

the emergency room for treatment, and the police had no involvement 

when Dr. Mott and nurse Knipper examined her. 

The majority cites no case holding that a statement made to a 

treating physician or nurse in the emergency room is “testimonial” for 

purposes of the Confrontation Clause. By definition, a statement made 

for purposes of medical treatment or diagnosis is not testimonial, as the 

Louisiana Supreme Court observed: “The statements at issue in the 

present case are also non-testimonial for purposes of the Sixth 

Amendment Confrontation Clause because they were not ‘procured [with 

a] primary purpose of creating an out-of-court substitute for trial 

testimony.’ ” Koederitz, 166 So. 3d at 986–87 (quoting Michigan v. 

Bryant, 562 U.S. 344, 358, 131 S. Ct. 1143, 1155, 179 L. Ed. 2d 93, 107 

(2011) (emphasis added)); see Bryant, 562 U.S. at 358–59, 131 S. Ct. at 

1155, 179 L. Ed. 2d at 107 (“In making the primary purpose 

determination, standard rules of hearsay, designed to identify some 

statements as reliable, will be relevant.”); White v. Illinois, 502 U.S. 346, 

356, 112 S. Ct. 736, 743, 116 L. Ed. 2d 848, 859 (1992) (“[A] statement 

made in the course of procuring medical services, where the declarant 

knows that a false statement may cause misdiagnosis or mistreatment, 

carries special guarantees of credibility that a trier of fact may not think 

replicated by courtroom testimony.”); cf. Melendez–Diaz v. 

Massachusetts, 557 U.S. 305, 312 n.2, 129 S. Ct. 2527, 2533 n.2, 174 

L. Ed. 2d 314, 322 n.2 (2009) (“[M]edical reports created for treatment 

purposes . . . would not be testimonial under our decision today.”); Giles 

v. California, 554 U.S. 353, 376, 128 S. Ct. 2678, 2692–93, 171 L. Ed. 2d 

488, 505–06 (2008) (“[O]nly testimonial statements are excluded by the 

Confrontation Clause. Statements to friends and neighbors about abuse 
33

and intimidation [by women in abusive relationships], and statements to 

physicians in the course of receiving treatment would be excluded, if at 

all, only by hearsay rules . . . .”). In any event, in this case, M.D., 

Dr. Mott, and nurse Knipper all testified live at trial subject to crossexamination. The majority’s reference to the Confrontation Clause is a 

red herring. 

III. Excited-Utterance Exception. 

Under the DeVoss rule, we may affirm an evidentiary ruling under 

any valid alternative ground supported in the record. See State v. 

Newell, 710 N.W.2d 6, 23 (Iowa 2006) (“Although we base our decision on 

a different rationale, we find no reversible error in the trial court’s 

ruling.”); DeVoss, 648 N.W.2d at 62–63 (noting that evidentiary rulings 

are an exception to our error preservation requirements and the district 

court ruling will be upheld if sustainable on any ground). In my view, 

M.D.’s statements to her doctor and nurse identifying Smith as her 

abuser were admissible under the excited-utterance exception. Iowa R. 

Evid. 5.803(2).6 

An excited utterance is “[a] statement relating to a startling event 

or condition made while the declarant was under the stress of excitement 

caused by the event or condition.” Id. “[S]tatements made under the 

stress of excitement are less likely to involve deception than if made upon 

reflection or deliberation.” State v. Harper, 770 N.W.2d 316, 319 (Iowa 

2009) (quoting State v. Tejeda, 677 N.W.2d 744, 753 (Iowa 2004)). We 

6When an alternative ground supports a ruling admitting evidence, the 

proponent should brief and argue the alternative ground on appeal. Otherwise, our 

court may defer deciding the issue until a case in which we have the benefit of 

adversarial briefing. 

 
34

consider five nonexclusive factors in determining whether a statement 

qualifies as an excited utterance: 

(1) the time lapse between the event and the statement, 

(2) the extent to which questioning elicited the statements 

that otherwise would not have been volunteered, (3) the age 

and condition of the declarant, (4) the characteristics of the 

event being described, and (5) the subject matter of the 

statement. 

Id. (quoting State v. Atwood, 602 N.W.2d 775, 782 (Iowa 1999)). 

Our court considered a similar fact pattern in Atwood. Atwood 

was charged with vehicular homicide after killing two pedestrians. 602 

N.W.2d at 777. Atwood’s passenger, Chris Sivertsen, was hospitalized. 

Id. at 782. A police officer interviewed Sivertsen approximately two and 

one-half hours after the accident. Id. The officer spoke with Sivertsen 

for about four to six minutes. Id. The officer asked Sivertsen what 

happened, and Sivertsen responded the defendant “jerked the wheel—or 

steering wheel way too hard and I thought he was mad.” Id. We held the 

statement was admissible. Id. at 783. We noted that Sivertsen had been 

through a very traumatic experience; “he had just been involved in a 

serious car accident and had apparently seen a child hit the windshield.” 

Id. We did not find that the time-lapse or the officer’s question brought 

the statement outside the excited-utterance exception. Id. at 782.7 

7We have applied the excited-utterance exception after significantly longer timelapses. See State v. Galvan, 297 N.W.2d 344, 347 (Iowa 1980) (holding the passage of 

two days “leaves [the evidence] close enough to the transaction so that the trial court 

could have believed any presumption of fabrication was excluded”); State v. Stafford, 

237 Iowa 780, 785–87, 23 N.W.2d 832, 835–36 (1946) (holding statements made 

fourteen hours following the alleged crime satisfied “the test of spontaneity” and were “a 

natural expression of what had happened to [the victim]”). But see Tejeda, 677 N.W.2d 

at 754 (finding a thirty-minute time gap between the startling event and the statement 

“weigh[s] heavily against the [statement’s] admission”). 

 
35

The circumstances surrounding M.D.’s statements show her 

statements to Knipper and Dr. Mott were excited utterances. M.D. was 

extremely upset from the time she called 911 through her emergency 

room visit. She was anxious, in pain, and separated from her daughter 

in the middle of the night. Against this backdrop, M.D. twice identified 

Smith as her abuser in response to the first question asked by the nurse 

and then to another asked by the doctor—“what happened?” The 

substance of M.D.’s statement was the very reason she was so upset—

because she had been assaulted by her intimate partner, the father of 

her child. We have found the excited-utterance exception applies in 

similar circumstances. See State v. Richards, 809 N.W.2d 80, 95 (Iowa 

2012) (holding domestic violence victim’s statement to her daughter that 

the defendant had put a cane to her neck was an admissible excited 

utterance because the victim had just come down the stairs, she “was 

upset and crying,” and her “neck was red”). 

Accordingly, I would affirm the district court’s admission of those 

statements as excited utterances. I agree with the court of appeals that 

any error in allowing the police officer to testify about what M.D. told him 

was harmless error. For these reasons, I would affirm the judgment of 

the district court and decision of the court of appeals. 

Mansfield and Zager, JJ., join this dissent.