Assessment and documentation of injury requires taking a good history, doing an appropriate physical examination and recording the findings contemporaneously, clearly and unambiguously utilizing a combination of legible hand-written or computerized notes, body diagrams and photos of the injuries. Departments may create special formats to document the history and examination. This allows a systematic approach in examination of the individual and can help relate description of the wound in a logical progressive sequence (i.e. head to toe or front to back). This has been recommended in the guidelines issued by the Ministry of Health and Family Welfare for examination of rape survivors. General physical examination, investigations, clothing examination, collection of evidence and maintaining chain of custody, duration, nature and circumstances of the injuries, etc. are also discussed in this chapter.