The first duty of documentation is not to create a perfect file. It is to avoid making a difficult situation more dangerous.
Begin with safety and consent
Ask what the person wants, what could happen if information is shared and whether recording a name is necessary. Consent should be specific: agreeing to speak is not the same as agreeing to appear online.
Separate four things
Keep the reported fact, the source, what you observed directly and what remains uncertain in separate fields. This prevents an assumption from quietly becoming a claim.
Record dates, locations, institutions contacted and reference numbers where they exist. Keep original files unchanged and note when a copy has been edited or redacted.
Collect the minimum
Identity numbers, health information, children’s details and intimate images can create serious risk. If a piece of data is not necessary for the next responsible step, do not collect it.
A useful record is clear enough to follow and limited enough to protect the person behind it.
Link the record to a pathway
Documentation should answer a practical question: what decision, referral, complaint or advocacy step will this evidence support? If there is no clear purpose, collecting more information may not help.