how to write a patient case report example

by Chelsey Quigley 8 min read

Writing A Case Report - Michigan State University

19 hours ago If required, it is recommended you obtain informed consent before the case report is written. An example of a case report consent form can be found on the BMJ Case Reports website, which you can access via the MSU library page - https://lib.msu.edu/medicalwriting_publishing/. Go to "Instructions for Authors" and then "Patient Consent" to find the consent form they use. >> Go To The Portal


Writing Your Patient Case Study.

  • 1. Work on Your Introduction. Select a case. You have to identify your focus and scope for the study. Like other research papers, you should prepare a ...
  • 2. Get to Know the Participants.
  • 3. Perform Data Analyses Method.
  • 4. Report the Case Study Results.

III. Patient case presentation
  1. Describe the case in a narrative form.
  2. Provide patient demographics (age, sex, height, weight, race, occupation).
  3. Avoid patient identifiers (date of birth, initials).
  4. Describe the patient's complaint.
  5. List the patient's present illness.
  6. List the patient's medical history.
Oct 1, 2006

Full Answer

How to write a report based on a case study?

  • The title should contain a phrase like case study or case report, so that readers understand what type of study it is.
  • An effective title might also say what condition the patient had, how it was treated, and whether the outcome was successful.
  • Most titles are less than 10 words long.

Can I write my own case report?

You can write a report and ask the judge to consider it, and if the circumstances are complex, probably should — same if the damages are composed of more than a few items, and you can attach receipts, etc. Remember, whatever you submit to the judge you must submit an exact copy to the other side, so you will need a total of three copies (one for yourself).

How to actually get your patients to write a review?

Are you posting a comment because:

  • You want to help others by providing genuine insights?
  • You are furious and feel the need to vent?
  • You are seeking revenge for a high bill or a canceled appointment?
  • You are a serial poster who simply likes posting across all social platforms?

Where can I publish a case report?

Tools to Use When Deciding Where to Publish

  • Jane (Journal / Author Name Estimator) Search for journals that might be interested in publishing your article. ...
  • Journal Citation Reports Weighs and ranks journals by a number of criteria. ...
  • Journal Citation Reports Quick Reference Cards Handout showing how to use JCR including definitions of various metrics and screenshots.

More items...

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How do you write a nursing case report?

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 write a medical case sheet?

Case sheet-of-history Stand on the right side of the patient with good confidence . Introduce yourself as a medical student not as a doctor . ( you may face difficult question ). Talk the patient gently with clear comprehensible words . Remember don't hurt the patient in your speak & touch .

How do you present a patient's case?

Case: Tom MurphyPresenting problem. You should start with a sentence that includes the patient's name, sex (Mr/Ms), age, and presenting symptoms. ... History of presenting problem. ... Medical and surgical history. ... Drugs. ... Family history. ... Social history. ... Review of systems. ... Findings on examination.More items...•

How do you write a clinical 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 start 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.

How do you write a patient medical report?

HOW TO WRITE A MEDICAL REPORTKnow that a common type of medical report is written using SOAP method. ... Assess the patient after observing her problems and symptoms. ... Write the Plan part of the Medical report. ... Note any problems when you write the medical report.More items...

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.

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.

What is the format of case study?

Follow these rules for the draft: Your draft should contain at least 4 sections: an introduction; a body where you should include background information, an explanation of why you decided to do this case study, and a presentation of your main findings; a conclusion where you present data; and references.

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.

How long should a medical case report be?

The word count for case report may vary from one journal to another, but generally should not exceed 1500 words, therefore, your final version of the report should be clear, concise, and focused, including only relevant information with enough details.

What is a patient care report?

A patient care report is a document made mostly by the EMS or EMTs. This documented report is done after getting the call. This consists of the inf...

What should not be written in a patient care report?

What should be avoided in a patient care report is making up the information that is not true to the patient. This is why you have to be very caref...

Who is in charge of reading the patient care report?

The person or the people who will be reading the report are mostly medical authorities. When you are going to be passing this kind of report, make...

What Is a Patient Care Report?

We often hear of care reports based on by medical teams or by medical authorities. Yet, we are not sure how this differs from the kind of report that is given to us by the same people. So this is the time to make it as clear as possible.

How to Write a Patient Care Report?

Where do you even begin when you write a patient care report? A lot of EMS or EMTs do know how to write one since they are trained to do so.

What is a patient care report?

A patient care report is a document made mostly by the EMS or EMTs. This documented report is done after getting the call. This consists of the information necessary for the assessment and evaluation of a patient’s care.

What should not be written in a patient care report?

What should be avoided in a patient care report is making up the information that is not true to the patient. This is why you have to be very careful and very meticulous when writing these kinds of reports. Every detail counts.

Who is in charge of reading the patient care report?

The person or the people who will be reading the report are mostly medical authorities. When you are going to be passing this kind of report, make sure that you have all the information correctly. One wrong information can cause a lot of issues and problems.

What is a patient case study?

Writing Your Patient Case Study. Since patient case studies are generally descriptive, they are under the a phenomenological principle. This means that subjectivity is entertained and allowed in research design. The medical scenarios are open to the researcher’s interpretation and input of insights.

What is a case study?

Case studies are a qualitative research method that offers a complete and in-depth look into some of the situations that baffled medical science. They document the cases that escape the ordinary in a hospital that has seen a manifold of plights. They serve as cautionary tales of the intricacy in dealing with human health.

How do case studies make a difference in the medical arena?

Patient case studies make a difference in the medical arena by reporting clinical interactions that can improve medical practices, suggest new health projects, as well as provide a new research direction. By looking at an event as it exists in the natural setting, case studies shed understanding on a complex medical phenomenon.

Why do medical practitioners use case studies?

Medical practitioners use case studies to examine a medical condition in the context of a research question. They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. The following are case study samples and guides on case presentation.

Why should you indicate the general scope and limitation of your work?

Because you are studying a case valid only for some people as of the moment, you should indicate the general scope and limitation of your work. The scenario might be different when placed in a different context. You should be honest in reporting the information about your study. Disclose the limits of your findings.

Is a clinical interaction report valid for generalization?

Since it documents stand-out clinical interactions where a single person or a few number of people are a party of, the findings may not be valid for generalization for a wider population.

Can you generalize a population using one case study?

You cannot generalize a population using one case study. However, multiple case study contains two or more cases under the point of interest can give you a replicated result. When the findings remain true for several cases under this research method, your case study’s results become more reliable.

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.

How many eggs should an 88 year old man eat a day?

Example 1: Normal plasma cholesterol in an 88-year-old man who eats 25 eggs a day. This is the case of an old man with Alzheimer’s disease who has been eating 20-30 eggs every day for almost 15 years. [ Source]

Why is a control group important?

A control group is important to eliminate the role of external factors which can interfere with the relationship between exposure and disease. Unmeasured Confounding caused by variables that influence both the exposure and the disease. A case report can have a powerful emotional effect (see examples of case reports below).

What is an example of recovery from the passage of an iron bar through the head?

This is an interesting case of a construction foreman named Phineas Gage. [ Source] In 1848, due to an explosion at work, an iron bar passed through his head destroying a large portion of his brain’s frontal lobe.

What is a case report?

Case Report: A Beginner’s Guide with Examples. A case report is a descriptive study that documents an unusual clinical phenomenon in a single patient. It describes in details the patient’s history, signs, symptoms, test results, diagnosis, prognosis and treatment.

Why do we need case reports?

Case reports offer, in general a fast, easy and cheap way to report an unusual observation or a rare event in a clinical setting, as these have very small probability of being detected in an experimental study because of limitations on the number of patients that can be included.

Is a case report representative of the entire population?

So, results from a case report cannot be representative of the entire population.

Is a case report causal?

Observing a relationship between an exposure and a disease in a case report does not mean that it is causal in nature. The absence of a control group that provides a benchmark or a point of reference against which we compare our results. A control group is important to eliminate the role of external factors which can interfere with ...

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Abstract

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.6,7 Supplementary parts such as tables, figures, graphs, and illustratio...
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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 merit of the case report and the …
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Conclusion

  • Patient case reports are valuable resources of new and unusual information that may lead to vital research.
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Appendix A—Criteria For Publishable Case Reports

  • Publishable patient case reports include cases that: 1. Advance medical science and spawn research; 2. Describe rare, perplexing, or novel diagnostic features of a disease state; 3. Report therapeutic challenges, controversies, or dilemmas; 4. Describe a new surgical procedure; 5. Report how a drug can enhance a surgical procedure; 6. Teach humanistic lessons to the health …
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