Use a repeatable note shape
Follow the same order each time: context, observation, interpretation, action, outcome, uncertainty, and next check. Context says where, when, and under what conditions the note was made. Observation records what was directly seen, heard, measured, received, or done. Interpretation explains what the observation might mean, clearly marked as judgment rather than fact. Action states what changed because of the note. Outcome records what followed, even if nothing happened. Uncertainty names what is missing, unclear, or assumed. Next check gives a concrete follow-up point.