Include full name, qualifications, job title and
how long you have been doing it.
Don’t assume reader knows anything about the
Use first person
Who did what, why, when
Concentrate on your observations and your
understanding (no need for long quotes of what was said to you, which is what a
clinical report would require)
Say what you found, but also what you looked for
and didn’t find
If you’re not exactly sure what you did, and
nothing documented, acceptable to say “My normal practice would be…”
When you have referred to or discussed with
someone else, give their name and who they are, describe what they did on the
basis of the notes and your understanding, but don’t comment on the adequacy or
otherwise of their performance.