In this Article you will Learn about Record Keeping
Learn what is Record Keeping in Homoeopathy
Record Keeping in Homoeopathy
Homeopathic case taking is the individual examination of the patient. Individual examination and understanding the peculiarity of a person’s suffering is not a simple task. So, noting down all minutest symptoms of the patient is mandatory. No human brain can remember or recall all the symptoms of each patient for a long period of time. Hence it is mandatory to note all the symptoms narrated by the patient in a legibly recorded form. A well noted case can be used as a clinical record for further reference, teaching and as a reliable source of research work. In homeopathy, after case taking is over, the recorded data is used for analysis and synthesis of case and the evaluation of symptoms.
In the footnote to § 104, Hahnemann criticizes the allopathic physicians for not showing much importance in record keeping. “No allopathic physician, as has been said, sought to learn all the minute circumstances of the patient’s case, and still less did he make a note in writing of them”. Hence, for a homeopathic physician especially when dealing with chronic cases, “Record keeping” becomes inevitable.
The clinical record of the patient must contain a minimum of the following items:
1. The preliminary data of the patient (like name, age, sex, occupation, marital status, address and religion, etc).
2. The symptoms collected by the patient, attendees and the physician himself, in the chronological order. The complete and comprehensive history of patient and his sufferings.
3. The past, present, treatment and personal history of the patient.
4. The clinical and laboratory findings.
5. The diagnosis of the condition.
6. Analysis of the case.
7. Evaluation of the symptoms and case analysis.
8. The first prescription and general management
9. The follow up.
No fixed format for case taking is recommended by Hahnemann. Based on his requirement, the physician can adopt a method which perfectly suits the condition. Most of the private practitioners follow “the bound register” method for record keeping. Either the “leaf folder method” or the “card system” is adopted by the medical institutions.
Uses of Record Keeping
1. The record keeping helps in “trinity of diagnosis”. The recorded symptoms guide us in “miasmatic diagnosis”, “constitutional diagnosis” and “remedial diagnosis”. In each area of diagnosis, symptoms are the only source.
2. The record keeping helps in selection of the remedy. From the recorded symptoms we can easily strike out the common symptoms of the disease, and the remedy can be selected on the basis of individualistic symptoms.
3. Record keeping helps in writing down symptoms told by the patient in his own words. This helps in understanding the subjective feelings of the patient as they are. Even in the long course of time, the case remains fresh as narrated by the patient.
4. Dr.Kent says, “Without the record you are at the sea without compass and radar”.
5. H.A.Roberts says, “We cannot depend upon our memory in taking the case. So as the first requisite in taking the case, you must have your records with you to note down the case as it is taken”.
6. Evaluation and analysis of the case is must after taking the case. Only by record keeping one can do such task.
7. The record keeping helps in follow up of the case. In making the first and subsequent prescriptions, for observing the appearance of new symptoms and the disappearance of the symptoms “record keeping” is must.
8. The record keeping helps in predicting the future course of the disease. Recording the symptoms in chronological order helps the physician in understanding the curative order of the symptoms. It also helps in observing the law of direction of cure in a case.
9. The recorded case can be easily communicated to the other medical fraternity. It helps in getting “second opinion” from experienced, senior physicians.
10. Homeopathy claims of curing some difficult and incurable diseases as termed by allopathy. Such claims can only be proved as facts by record keeping as it works as evidence based claim.
11. For research oriented work, record keeping is a must, as research believes in quantitative study as well as qualitative one. All the above reasons highlight the importance of record keeping in managing the case in a credible, legible and successful manner.
