Homeopathy Tips for 3/31/15 Proper Case Recording
One of the most basic and simple habits a homeopath needs to develop is proper case recording. This is an essential tool and behavior necessary for good case management and being able to share your cases. Getting this procedure to become a habit will make all of your cases better and your ability to help your client will improve.
Every case begins before the client even arrives. There is an energy that builds as the clients comes to the appointment. It can even start days before. This is something that the client will experience. They will bring this with them as they walk through the door. This is when the case begins for the homeopath. Often this initial meeting will be the most important part of the case. Pay close attention and as the case gets written include any remarks or gestures made during this time.
I have my clients fill out a simple information form while they sit before me. This allows me to observe them and gather some vital information about them. This is simple and is not a full health history. It includes contact information, any medications they are currently taking, whether they have had cancer of any type, and what their main complaint is. I do not use a long symptom checklist for them to fill out. I prefer to have them share with me in their own words how they suffer. This will be a pure expression of the vital force and not a word or two that will only partially describe what the symptom is. Avoiding this checklist will keep the charge of them needing to tell me rather than it being discharged with a check on the paper. I have seen this before and the client said they didn’t think they needed to talk about it since it was already checked off. The real way to understand the symptom will be in the story they tell about it. It will bring it from content to context.
The need to record verbatim the case is absolutely essential. This can not be overlooked. It is not enough to just jot down a few ideas about the case. The case needs to be recorded so that you can go back and review. Even during the case I will not interrupt them if I hear something unusual but I will put a star or underline the passage so I know to come back and ask for more details. Some homeopaths are better typists than myself and will type the case as it unfolds. I personally do not think this is a very good idea since the banging of the keys is like being a stenographer taking testimony. People will not be as open to the feeling of being on trial in a courtroom. I write longhand in cursive everything the client says. I can glace up and see them or stop to engage as necessary. It is also quiet and is not intrusive.
This task of writing must be developed. If there is a form of shorthand that you can learn it makes the job even easier. I have some students who say they can not keep up. If you get behind, make a quick note of the idea or key word from the time you are behind and then pick up again. Practice this and you will be able to keep up an entire case. I can read my cases and verbatim tell my client exactly what they said. When I look back during followups they are amazed at how I recorded exactly what they have said. It is very helpful to have this tool.
Other homeopaths will video or audio record the case. I find that this is very useful as well but the need to still record the words on paper or into a file exists. This is not available during the appointment if there is no written record of the case to refer to. If the recording is lost then the case is lost also. I prefer to write longhand. An interesting fact I just learned is that in American grade schools longhand cursive writing is no longer being taught. This will soon be a lost art.
As the case develops I will make notes in the sidebar of the paper. This will include observations. Maybe they make a gesture, or cry, or sniffle or sneeze. Anything that happens during the case I will note. I will also use the side bar of the paper to record my ideas as they pop up during the case. It could be an idea for the theme of the case, rubric or remedy.
Once the case is written and all testimony has been given it is time to undestand what is asking to be healed. This idea comes from the themes of the case. When I teach I will write the case verbatim on a big white board. Then I will go back with colored pens and circle or underline the themes of the case. Each color will represent the theme, idea, or collection of similar words. This will be the greatest help in understanding what is asking to be healed. When that is known it should be able to be shared in a very short concise sentence. If this essence is not understood it will be far too complex to simply translate into a theme and essence of the best remedy for the case.
Always include this idea in your recorded case. It is the basis for the prescription. Always include the rubrics chosen for the case. Write these down or print a record of the rubrics from the computer if you use a computer repertizing program. This will be the way to go back and rebuild the case or see a them from follow-up to follow-up.
If you are not an essence prescriber then there will be many remedies that may be applicable for the case. Write every remedy that has been considered for the case. Include a short sentence why this remedy is being considered for the case. This should include ideas about mental and physical aspects of the remedy. This is one of the most important parts of recording a case, especially if you have to present a case for certification approval or for publication. This is where your thinking about the case and remedies for consideration is expanded.
Once the final remedy has been chosen it is helpful to make a few notes about why this is the very best remedy and potency for the case. This is where you make your case for the remedy. It is such a very critical part of the process. I find students who find this the most difficult part of the task. They have ideas and are clear about them but to put those ideas that support their choice for a remedy can be very difficult. If you can not put your ideas about the remedy into words it will be very difficult to explain why you are giving the remedy to your client. Any case presentation will need to have this clearly stated.
Now that the case has been recorded it must have the date included and can be filed. Most computer programs have a case file manager. I personally do not use them. I keep all of my cases handwritten and in a file folder. For me this is the easiest way. I do not have to retype the case unless I am making the case for presentation. But for those who type they have eliminated this one step. I find typing very frustrating because I am not a very good typist. I do not retype very many cases either so I keep my frustration to a minimum.
Making these steps a habit are so very important to being a homeopath. As your business grows you will be referring to your notes all of the time. It is the basis for support of what you do. If there is not a good record of the case and what you have done then follow-ups will be deficient and your case will fall apart right before your eyes. You need an accurate record of each case client you are working with. Ethically it is required.