how to use patient initials in a case report

Can I use patients’ initials in the sponsor’s report?

A: To begin, patients’ initials are PHI, so if the sponsor’s intent is to use only de-identified patient data, initials will not work.

What should be in a patient case report?

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.

How do you list diagnostic procedures in a case report?

□ List the completed diagnostic procedures that are pertinent and support the case. □ Paraphrase the salient results of the diagnostic procedures. □ Provide photographs of histopathology, roentgenograms, electrocardiograms, skin manifestations, or anatomy as they relate to the case.

How do you write a report on a patient’s condition?

The author should establish a causal and temporal relationship and indicate the effect of treatment, any unanticipated effects, the patient’s final outcome, any further proposed treatments, and the patient’s present status at the time of the report. Patient demographics such as age, height, weight, sex, race, and occupation must be included.

How do you write names in case reports?

First, describe the patient's initial complaint and, if possible, use the patient's own words. Describe why the patient has come to YOU or your Hospital and who referred him/her to the current hospital. Briefly describe the patient, gender, ethnicity his chief complaint, medical history, family and social history.

How do you introduce a patient in a case study?

First, we describe the complaint that brought the patient to us. It is often useful to use the patient's own words. Next, we introduce the important information that we obtained from our history-taking. We don't need to include every detail – just the information that helped us to settle on our diagnosis.

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.

How do you write a clinical case report?

2:2137:49Writing Clinical Case Reports - YouTubeYouTubeStart of suggested clipEnd of suggested clipSearch is twofold. The first thing is that you want to verify that your case really is unique orMoreSearch is twofold. The first thing is that you want to verify that your case really is unique or unusual and secondly you want to provide the basis for the review of the literature. That's going to be

How do you present a patient with Ed?

A Guide to Patient Presentations in the Emergency DepartmentThe Title: A one-liner stating if they're sick or not sick and why they are here.The Journey: The story of what you think they have and why they don't have anything else (your history of present illness and relevant past history)The Buildup: Your focused exam.More items...•

How do you write a nursing case study example?

How to Write a Case Study Paper for NursingThe status of the patient. Demographic data. Medical History. ... The nursing assessment of the patient. Vital signs and test results. ... Current Care Plan and Recommendations. Details of the nursing care plan (including nursing goals and interventions)

How do you structure a case presentation?

SUMMARYSET THE STAGE.PROVIDE ONLY INITIAL CUES AT FIRST.ASK FOR HYPOTHESES AND WRITE THEM UP ON THE BLACKBOARD.ALLOW THE AUDIENCE TO ASK FOR INFORMATION.HAVE THE AUDIENCE RE-FORMULATE THEIR LIST OF HYPOTHESES.FACILITATE A DISCUSSION ABOUT REASONING.ALLOW ANOTHER ROUND OF INFORMATION SEEKING.More items...

What are the components of patient case presentation?

Highlighted in this chapter are the essential components of the presentation: the chief complaint, the history of present illness (HPI), the past medical history, the family and social history, the review of systems, and finally, the physical examination findings.

How do you start a case presentation?

How to Write a Case Study: a 4-Step FrameworkIdentify the Problem. Every compelling case study research starts with a problem statement definition. ... Explain the Solution. ... Collect Testimonials. ... Package The Information in a Slide Deck.

How is a report written?

Reports typically stick only to the facts, although they may include some of the author's interpretation of these facts, most likely in the conclusion. Moreover, reports are heavily organized, commonly with tables of contents and copious headings and subheadings.

What should be the introduction of a case report?

The introduction should be concise and immediately attract the attention and interest of the reader. The introduction should provide background information on why the case is worth reading and publishing, and provides an explanation of the focus of the case report, for example: “We present/report a case of ….”.

What is the role of case reports in medical imaging?

Two main roles are recognized for case reports published in medical imaging and radiology journals: as sources of new knowledge and as important means for education and learning.

What is case report?

Abstract. A case report is a description of important scientific observations that are missed or undetectable in clinical trials. This includes a rare or unusual clinical condition, a previously unreported or unrecognized disease, unusual side effects to therapy or response to treatment, and unique use of imaging modalities or diagnostic tests ...

Why are case reports important?

Although case reports are regarded by some as the lowest (some even do not list the case reports at all) in the hierarchy of evidence in the medical literature, publishing case reports allow for anecdotal sharing of individual experiences , providing essential sources of information for the optimum care of patients.

Should the author's interpretation or inferences be avoided in the body of a case report?

The author's own interpretation or inferences should be avoided in the body of a case report. Tables/figures should be used to reveal chronological findings or to compare observations using different methods.

Is a case report a literature review?

The discussion section of a case report is not designed to provide a comprehensive literature review and citation of all references; therefore, all the references cited should be critically evaluated. Any limitations of the case should be stated and the significance of each limitation described.

What is a case report?

Case reports generally involve the description of medical treatment in a patient or a few patients with a unique treatment, disease course, or outcome based on a retrospective review of medical records or they can involve a description of a unique diagnostic finding or uncommon presentation .

Is a case report considered human subjects?

Several major research institutions have concluded that a case report involving the description of the medical cases of three or fewer patients does not constitute human subjects research and is therefore exempt from IRB review.

Can a case report be a biospecimen?

In addition, testing of a patient's biospecimen (e.g., special stain, immunohistochemistry, molecular studies) is not typically permissible as part of a case report.

Do I need to acknowledge an IRB?

Many journals require acknowledgement from an IRB prior to publication of a single case report or a case series. If asked to provide acknowledgement from the IRB prior to publication, either use this guidance as documentation from the IRB or contact the Health Sciences IRBs Office for assistance.

What is a CRF in clinical research?

Case report form (CRF) is a specialized document in clinical research. It should be study protocol driven, robust in content and have material to collect the study specific data. Though paper CRFs are still used largely, use of electronic CRFs (eCRFS) are gaining popularity due to the advantages they offer such as improved data quality, ...

Why are answers coded?

In some places, answers are coded in order to simplify the data collection. When codes are used to obtain an answer for a question, consistency in codes should be maintained throughout the CRF booklet and there should not be any variation in the answer for the same question.

What does a covered entity need to do?

The Covered Entity needs to contractually obligate the sponsor (or other recipient) via the clinical trial agreement and/or a data use agreement, to limit uses or disclosures as spelled out in the Authorization, unless the use/disclosure is otherwise required or permitted by law.

Is a business associate liable for PHI?

Since the advent of the HITECH Act, Business Associates are directly liable for protecting PHI (although Business Associates are not required to comply with every aspect of HIPAA). If the private company is a Business Associate, it is hopefully aware of this legal obligation and following HIPAA appropriately.

Why are client initials considered to be identifying?

A client’s initials are considered to be identifying for the purposes of determining if a given piece of information is PHI under HIPAA, because they are derived from names. Even though most people couldn’t identify a client from just their initials, some people can. The same can be said of using only a client’s first names or last names.

Is it legal to discuss a client's case with a colleague?

It’s generally acceptable to discuss a client’s case with a colleague when we deidentify the client. HIPAA sees it the same way: deidentified information is not Protected Health Information, and is therefore not covered by HIPAA. Fortunately, the HIPAA Privacy Rule has a safe harbor method for deidentifying information.

Is there a safe harbor for deidentifying information?

Fortunately, the HIPAA Privacy Rule has a safe harbor method for deidentifying information. Because it’s a safe harbor, you can consider any information about a client to be deidentified if you are able to remove all 18 of the identifiers on the list below. Take a look at it. The Safe Harbor Method of Deidentification’s Identifiers List.