In this guide 6 sections
One patient file should hold the case form, the remedy notes, the prescription, the potency history and the review date for every visit. Return visits open on the last prescription. The doctor decides each remedy. The file keeps the reasoning beside it.
What a case form needs to hold
A homeopathic case form covers complaints with their modalities, mental and physical generals, family history and past illness, and it runs far longer than a general consultation note. Thirst, sleep, appetite and the patient’s response to heat and cold are recorded as generals, while sensations and locations belong beside each complaint. Detail is the whole point.
Order matters to each doctor. A form that differs from the paper one slows the consultation, so the headings should match what the doctor already writes by hand.
Images belong in the file too. A skin complaint can be compared across visits by looking at dated images, and old reports sit beside the new notes without a hunt through cupboards.
- Complaints and their modalities
- Mental and physical generals
- Family history and past illness
- Scanned reports and photographs
Keeping the reasoning with the case
The prescription is just the last line. The symptoms weighed and the remedies compared come first, and without a note they vanish from memory long before the next visit.
Remedy selection notes keep that working inside the case by listing the symptoms chosen, the remedies considered and the reason for the final choice. Rubrics chosen from the repertory can be typed beside each remedy considered, so the reason for a first prescription is readable months later.
The software does not suggest a remedy. It stores what the doctor decided and why, so a change of potency next time has a visible reason that any colleague covering the clinic can read.
Writing the prescription in full
A prescription names the remedy, the potency, the form of medicine, the dose and how often it repeats, and a placebo is written down in the same way.
The entry saves to the case, prints in the clinic’s format with its registration details, and appears in the dispensary queue, where the medicine is prepared from it.
Fix the remedy list first. Free-form typing of remedy names produces spellings that no report can group, while a fixed list with potencies lets the dispensary count stock remedy by remedy. Acute prescriptions for fever or diarrhoea and constitutional prescriptions for chronic complaints should keep separate headings, so a quick remedy for a cold never buries the long course.
- Remedy name and potency
- Form of medicine and dose
- Repetition and any placebo
- Registration details on the print
Recording how the patient reports
Each follow-up note records how the patient reports against the last prescription and sets the next review date, so a complaint is judged against its own history. Aggravation, amelioration and any new symptom are written under the date of the visit, turning a vague report of feeling better into entries a second doctor can read.
The case becomes a dated trail. The doctor reads that trail at the start of the visit, before the first question, instead of rebuilding the story from the patient’s memory.
Reception sees who is overdue for review. Reminders go out as chat messages, texts or emails, and a report lists patients who never returned after a first visit so the doctor can decide whom to call.
What the doctor decides before set-up
Three choices belong to the clinic. Decide which headings the form keeps, which remedies and potencies are listed, and who may read case notes before anyone enters a first patient.
Access follows the role. The doctor can lock notes away from the front desk, while reception keeps working with appointments, bills and review dates across the whole clinic. Reception, the dispenser and a visiting doctor each need a different slice of the file, so the access rule is easier to draw before launch than after a mix-up.
A small register works for now. Case history is the hardest part to move later, so start the digital file while the register is still small enough to copy by hand.
Case and prescription checklist
One page holds the whole checklist. List the headings of your case form, the fields of a prescription and the details of a follow-up note, then tick only what the doctor writes during a consultation. Unticked headings can go.
Open a blank worksheet to printQuestions owners ask
Can the doctor use their own case form?
The doctor’s own headings, rubrics and modalities are set up first, so case taking looks like the paper form it replaces, and changes follow on request.
How do old paper case histories move across?
Patient lists and open follow-ups come from the register or current software, and paper case history is scanned and attached to each file so earlier visits stay readable. Nothing is retyped from memory.
Who can read the case notes?
The clinic decides who reads them. Doctors can keep notes private while reception still works with appointments, bills and review dates, and the rule is fixed before the first patient is entered.