The notes in these cases are those more likely than any other to appear in court. Thus, all the principles of good notetaking - date and time, clarity, people present, signiture and designation - are particularly important. Black or blue ink should be used in case they need photocopying.
The history should include dates and times of all events, and should record any inconsistencies.
For physical findings a clear, dispassionate description, preferably accompanied by a witnessed photograph, is needed. Junior staff should avoid making inferences from any findings - for example they should describe four circular bruises 2cm in diameter on one side of an arm, and a similar bruise on the other, but should not write "Consistent with a gripping hand".
If any accusations or suggestions are made, or if it seems appropriate, it may be helpful to document the reactions of various people present.
Annotations allow you to add information to this page that would be handy to have on hand during a consultation. E.g. a website or number. This information will always show when you visit this page.