The Importance of Proper Case Recording

One of the most basic habits a homeopath needs to develop is proper case recording. This is an essential tool necessary for good case management and being able to share your cases. Making this procedure a habit will make all of your cases better and improve your ability to help your client.

Every case begins before the client even arrives. There is an energy that builds as the client 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 you begin to take your first notes for the case, include any remarks or gestures made during this time.

I have my clients fill out a brief information form while they sit before me. This allows me to observe them and gather some vital information about them. The form 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 the case verbatim is absolutely essential. This cannot 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 it. 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 prefer to write longhand cursive. I can glace up and see them or stop to engage as necessary. It is also quiet and 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 cannot keep up. If you get behind, make a quick note of the idea or key word from the moment you feel 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 clients 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 record the words on paper or into a file still 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.

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, sniffle, or sneeze. Anything that happens during the case, I will note. I will also use the sidebar 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, a rubric, or a remedy.

Once the case is written and all testimony has been given, it is time to understand 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 whiteboard. Then I will go back with colored pens and circle or underline the themes of the case. Each color will represent a 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 repertorizing program. This will be the way to go back and rebuild the case or see a theme from one follow-up to the next.

If you are not an essence prescriber, then there will be many remedies that may be applicable to the case. Write every remedy that has been considered for the case. Include a short sentence of 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 critical part of the process. I find students find this the most difficult part of the task. They have ideas and are clear about them but choosing those ideas that support their choice for a remedy can be very difficult. If you cannot 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.

Once 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 and do not retype the case unless I am making the case for presentation. This is ultimately up to you.

Making these steps a habit is 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 and, ethically, it is required.