7. Note-taking for legal purposes

Your notes may be required as evidence, if charges are laid against the perpetrator.

If family violence is a concern, you should keep detailed notes that:

  • Describe physical injuries (including the type, extent, age and location). If you suspect violence is a cause, but your patient has not confirmed this, include your comment as to whether her explanation accurately explains the injury.
  • Record what the patient said (using quotation marks)
  • Record any relevant behaviour observed, being detailed and factual rather than stating a general opinion, e.g. rather than ‘the patient was distressed’, write ‘the patient cried throughout the appointment, shook visibly and had to stop several times to collect herself before answering a question’.

Consider taking photographs of injuries, or certifying photographs taken of the injuries presented at the time of consultation.

To be good evidence in court, file notes must include date and time, and clearly identify the client. You must clearly identify yourself as the author, and sign the file note. Do not include generalisations or unsubstantiated opinions. Correct and initial any errors, set out your report sequentially, and use only approved symbols and abbreviations.

 6. Victims support scheme

8. Mandatory reporting