Recording and Interpretation
Need of a case record has been emphasized by all the stalwarts
for various essential purposes. Every case can be a piece of learning.
Therefore, it is imperative to have it recorded properly. Since
it is almost impossible to keep all the data intact without any
distortion, the necessity of a proper recording has been felt acutely.
The purpose of a case record is to keep all the information adequately
and accurately recorded for future references. Case record should
communicate the exact picture of the patient which has been obtained
by the physician. This is possible only when recording is done
properly without being hindered by any subjectivity of the physician.
While giving directions for investigating the case, Master Hahnemann
has greatly emphasized the necessity of being unprejudiced and
stressed the need of fidelity in tracing the picture to overcome
the subjectivity in practice.
Very often it is noticed that all the information of the sick
person do not find a place in case record. While the physician might
fail to record some information, he might unduly focus on some other.
All the events and effects should be recorded without any interpolation
or deletions. While recording, beginners are cautioned not to get
influenced by the symptoms of drugs as recorded in the Materia
Medica.
Very often the use of technical terms can create confusion, so
it should be avoided, but at the same time, physician should apply
common sense while noting down the picture in patient’s own language.
In our practice, for instance, we come across many cases where patient
shows hypogastruim and says, “ Doctor, I have got stomach ache.”
For gas (flatulance) complaints, some patients might say “I have
got gastric,” etc. Whatever the patient is trying to communicate
should be properly received and interpreted by the physician. The
physician should be careful while interpreting the words of the
patient as the prejudices of the physician might crawl in here without
his awareness.
Though much is said about prejudice, it is an accepted fact that
remaining unprejudiced is not an easy task. Kent once stated “It
would almost seem impossible to find at the present time one who
could be thus described (unprejudiced)” To be unprejudiced is to
be aware of our own prejudices. Once we are aware of them, the chances
of committing wrong interpretations and recording them would be
less.
Intensity of symptom should also be given due consideration while
recording. Each and every symptom should be recorded by putting
marks above it.
For example: Salt
craving 3 (more intense)
Salt
craving 2 (intense)
Salt craving (moderate)
For effective repertorisation, precise recording is very crucial
for proceeding further with the subsequent steps. Recording is not
done independent of interpretation; so both should be done simultaneously.
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