case report patient information section

The format of a patient case report encompasses the following five sections: an abstract, an introduction and objective that contain a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion.

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How to write a case study on a patient?

Writing Your Patient Case Study

1. Work on Your Introduction Select a case. You have to identify your focus and scope for the study. ...
2. Get to Know the Participants You can have one or multiple case participants. ...
3. Perform Data Analyses Method Your results will depend on your interpretation of the raw data. ...
4. Report the Case Study Results

How to write a patient care report?

Patient-Centered Care Report example

• Attach a reference list to your report. ...
• Describe the outcomes that were not achieved, the extent to which they fell short of expectations, and any variance across demographic groups.
• Identify the factors (for example: institutional, community, environmental, resources, communication) that may have contributed to any achievement shortfalls. ...

More items...

How to write a medical case report?

Writing up. Write up the case emphasising the interesting points of the presentation, investigations leading to diagnosis, and management of the disease/pathology. Get input on the case from all members of the team, highlighting their involvement. Also include the prognosis of the patient, if known, as the reader will want to know the outcome.

How to review a case report?

related reports, are provided. SUMMARY: The format of a patient case report encompasses the following five sections: an abstract, an introduction and objective that contain a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion.

What to ask for in a case report?

Do you need informed consent for a journal?

About this website

What are the sections of a case report?

Case reports should encompass the following five sections: an abstract, an introduction with a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, and a brief summary of the case and a conclusion.

What information should be recorded in a case report?

GENERAL PRINCIPLES OF CASES REPORT The case report is a research design where an unexpected or novel occurrence is described in a detailed report of findings, clinical course, and prognosis of an individual patient, which might be, but not mandatory, accompanied by a review of the literature of other reported cases.

How do you write a patient case report Example?

Format of the patient case report. Case reports should encompass the following five sections: an abstract, an introduction and objective with a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion.

Do you need patient consent to write a case report?

Although not technically required, especially if the case report does not include any identifying information, some journals require informed consent for all case reports before publishing. The CARE guidelines recommend obtaining informed consent AND the patient's perspective on the treatment/outcome (if possible).

How do you write a patient case summary?

How do you write a patient case report?Describe the case in a narrative form.Provide patient demographics (age, sex, height, weight, race, occupation).Avoid patient identifiers (date of birth, initials).Describe the patient's complaint.List the patient's present illness.List the patient's medical history.

How do you present a case report?

Case Presentation. The case report should be chronological and detail the history, physical findings, and investigations followed by the patient's course. At this point, you may wish to include more details than you might have time to present, prioritizing the content later.

What should a patient case study include?

Case: This section provides the details of the case in the following order:Patient description.Case history.Physical examination results.Results of pathological tests and other investigations.Treatment plan.Expected outcome of the treatment plan.Actual outcome.

How do you write a case report introduction?

First, you want to introduce the topic not discuss the actual case. Therefore, you should not include details about your client until the case description section. The introduction should only give the background on why this case report was written and some background on the condition of interest.

How do you write a case report PDF?

The sections of the case report are the title, abstract with keywords, introduction, case description, discussion with conclusions and references. The case report should be clear, concise, coherent, and must convey a crisp message. Common pitfalls and mistakes will be discussed.

Does a case report need IRB approval?

Under HIPAA, a case report is an activity to develop information to be shared for medical/educational purposes. Although the use of protected health information to prepare the paper does not require IRB review, the author of a case report must comply with HIPAA.

How do you take consent from a patient to a case report?

Consent to use a patient's story should be obtained prior to publishing the report wherever possible. This consent should be obtained directly and preferably in writing from the individual affected. A suitable consent form is provided here. To not obtain consent for a case report requires justification.

Do case reports require ethical approval?

Case reports and studies intended for quality improvement are often considered not research and do not need IRB approval. Nevertheless, there should be some processes of clearing those studies with respect to ethical handling of patients and related data.

Standard Case Report checklist and template for authors

I, [INSERT YOUR NAME IN FULL], the Author has the right to grant and does grant on behalf of all authors, an exclusive licence and/or a non-exclusive licence for contributions from authors who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance with the relevant stated licence terms for US Federal Government Employees acting in the course ...

Writing a case report in 10 steps | The BMJ

Coming up with a title. Discuss a title with your supervisor and other members of the team, as this provides the focus for your article. The title should be concise and interesting but should also enable people to find it in medical literature search engines.

Writing a Case Report - How To's &Tips | Examples

Examples of Writing an Inspection Report; 5+ Ways of Writing an Observation Report Examples; Writing a case report for school is a practice for students who will eventually work in fields such as companies and organizations, and they have to make their own case report; but this time with no guidance from a professor.

Case Report Form: Types Uses & Template Examples

Case report forms are one of the most important data instruments used for clinical researches and medical examinations. When conducting clinical trials, the researcher needs to record even the smallest of observations as they happen.

What to ask for in a case report?

It is often best to ask for informed consent and the patient’s perspective before you begin writing your case report. Appendices (If indicated). Submission to a scientific journal. Follow author guidelines and journal submission requirements when writing and submitting your case report to a scientific journal.

Do you need informed consent for a journal?

The patient should provide informed consent (including a patient perspective) and the author should provide this information if requested. Some journals have consent forms which must be used regardless of informed consents you have obtained. Rarely, additional approval (e.g., IRB or ethics commission) may be needed.

What is a case report?

Wikipedia [ 9] has this to say: “In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence.

What is the introduction of a case report?

The Introduction ( JMCR) or Background ( BMCRN) section should explain the background of the case, including the disorder, usual presentation and progression, and an explanation of the presentation if it is a new disease. If it is a case discussing an adverse drug interaction the Introduction should give details of the drug’s common use and any previously reported side effects. It should also include a brief literature review. This should give an introduction to the case report from the standpoint of those without specialist knowledge in the area, clearly explaining the background of the topic. It should end with a very brief statement of what is being reported in the article.

What is JMCR journal?

JMCR is an online, open access journal under BMC auspices dedicated mainly to the publication of high quality case reports, and aims to contribute to the expansion of current medical knowledge (please see specific publication criteria below).

When did JMCR come out?

Since the launch of JMCR in 2007 and the more recent introduction of case reports to the BMCRN, which aims to have a broader scope, BMC has acknowledged and continues to acknowledge the value of case reports to the scientific literature.

How many BMC journals are there?

The BMC series is a group of open access, peer-reviewed journals that spans most areas of biological and clinical research. There are currently 65 journals in the series, including (alphabetically) BMC Anesthesiology to BMC Women’s Health.

What is the author's information section?

This section includes any relevant information about the author (s) that may aid the reader’s interpretation of the article and understanding of the standpoint of the author (s ). This may include details about the authors’ qualifications, current positions they hold at institutions or societies, or any other relevant background information. Please refer to authors using their initials. Note this section should not be used to describe any competing interests.

What should be included in a case presentation?

The Case presentation section should contain a description of the patient’s relevant demographic information (with out adding any details that could lead to the identification of the patient); any relevant medical history of the patient; the patient's symptoms and signs; any tests that were carried out and a description of any treatment or intervention. If it is a case series, then details must be included for all patients. This section may be broken into subsections with appropriate subheadings.

What is a case report?

Case report definition states that in medical practice, it is a paper documenting the diagnosis, symptoms, applied treatment and case follow up of a patient. Case reports serve as the first-line piece of evidence in medical literature. The purpose of a case report is to communicate evidence-based information on clinical trials.

What is the first page of a case report?

You can take assistance from the given format generally adopted for writing the case report: 1. Title Page. The first page must be a title page, including a short, comprehensive description of your manuscript, full names of author and participants, institutional and email addresses.

What is the conclusion of a case report?

Conclusion: The conclusion is a summary of the findings and learning points for the medical professionals, including clinical impacts of the case report. The conclusion also lists if the report deals with a specific clinical specialty or it will have a clinical impact on a broader spectrum.

Why are case reports important?

Case reports have become a rapid dissemination of knowledge for a medical audience. From diagnosis of a medical condition to scientific observations and the optimal course of treatment, a case report presents clinical insights, aiming to expand medical knowledge.

Is a case report a formal report?

Overall, reports adhere to a formal case report format but if you have a passion to share your medical experience and insights with people, it can become a lifelong hobby. Thus , the above-mentioned guidelines will definitely help you write a coherent, clear and impactful case report for publication to benefit the scientific community.

Can you add reflection to a case report?

You can add patient’s reflection about his disease, his experiences while seeking medical advice and treatments, and description of symptoms. However, to avoid making it subjective or patient-centered, you should add only relevant details in the report.

Is a case report mandatory in JMCR?

It is a compulsory section in both JMCR and BMC guidelines. You need to seek the patient’s consent for publishing his case report in the medical journal. You have to submit a statement in writing to the BMC along with your manuscript.

What is data availability statement?

Data availability statements should include information on where data supporting the results reported in the article can be found including, where applicable, hyperlinks to publicly archived datasets analysed or generated during the study. By data we mean the minimal dataset that would be necessary to interpret, replicate and build upon the findings reported in the article. We recognise it is not always possible to share research data publicly, for instance when individual privacy could be compromised, and in such instances data availability should still be stated in the manuscript along with any conditions for access.

What is a footnote in a bibliography?

Footnotes can be used to give additional information, which may include the citation of a reference included in the reference list. They should not consist solely of a reference citation, and they should never include the bibliographic details of a reference. They should also not contain any figures or tables.

What is a case report?

A case report is an unsystematic clinical observation that states the outcome or response of a single patient to a diagnostic strategy or treatment . Case reports serve to document and share novel cases amongst the medical community for educational purposes.

When case reports describe or discuss unique or rare circumstances, as they often do, it may be difficult or impossible to answer

When case reports describe or discuss unique or rare circumstances, as they often do, it may be difficult or impossible to de-identify those cases such that there is no reasonable expectation that the individuals included can be identified, so patient authorization generally would be required.

What is PHI in healthcare?

This is known as safe harbor de-identification.

When safe harbor de-identification is not possible or the opportunity to identify the patient exists, even after de-ident

When safe harbor de-identification is not possible or the opportunity to identify the patient exists, even after de-identification, the expert determination method for de-identification can be considered. For purposes of de-identification, an expert is defined as: A person with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods for rendering information not individually identifiable:

Is PHI de-identified under HIPAA?

It is important to understand that determining whether data are de-identified under HIPAA is a more restrictive determination than determining whether private information is individually identifiable under the Common Rule. The HIPAA rule considers PHI as any information that may identify an individual; was created or received by a member of a HIPAA covered entity; and relates to the individual's past, present, or future physical/mental health or condition, health care, or payment for health care. HIPAA recognizes two methods for de-identification of data.

What to ask for in a case report?

It is often best to ask for informed consent and the patient’s perspective before you begin writing your case report. Appendices (If indicated). Submission to a scientific journal. Follow author guidelines and journal submission requirements when writing and submitting your case report to a scientific journal.

Do you need informed consent for a journal?

The patient should provide informed consent (including a patient perspective) and the author should provide this information if requested. Some journals have consent forms which must be used regardless of informed consents you have obtained. Rarely, additional approval (e.g., IRB or ethics commission) may be needed.

Abstract

Format of The Patient Case Report

Summary

• Patient case reports are valuable resources of new and unusual information that may lead to vital research and advances in clinical practice that improve patient outcomes. Case reports should contain an abstract and four sections—an introduction, case presentation, discussion, and conclusion. The introduction provides the subject, purpose, and meri...

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Conclusion

Appendix A—Criteria For Publishable Case Reports