patient knowdelge case report

What do you need to know about patient case reports?

Patient case reports are valuable resources of new and unusual information that may lead to vital research. Patient case reports are valuable resources of new and unusual information that may lead to vital research. How to write a patient case report Am J Health Syst Pharm.

How do I write a case report with patient consent?

It is important to take written consent from the patient before you start writing your case report as all journals will require you to provide patient consent at the time of manuscript submission. In case the patient is a minor, parental consent is required.

What should you not disclose in a clinical case report?

Remember not to disclose any information that might reveal the identity of the patient. You need to be particularly careful with pictures, and ensure that pictures of the affected area do not reveal the identity of the patient. How is a clinical case report structured?

How to write a patient case study?

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 do you write a patient case report?

III. Patient case presentationDescribe 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.More items...•

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).

What is usually written in a patient's case history?

A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine.

What is the difference between case study and case report?

Case studies are widely used in psychology to provide insight into unusual conditions. A case study, also known as a case report, is an in depth or intensive study of a single individual or specific group, while a case series is a grouping of similar case studies / case reports together.

What makes a good 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.

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.

How do you take a case history of a patient?

Procedure StepsIntroduce yourself, identify your patient and gain consent to speak with them. ... Step 02 - Presenting Complaint (PC) ... Step 03 - History of Presenting Complaint (HPC) ... Step 04 - Past Medical History (PMH) ... Step 05 - Drug History (DH) ... Step 06 - Family History (FH) ... Step 07 - Social History (SH)More items...

What is meant by case report?

Listen to pronunciation. (kays reh-PORT) A detailed report of the diagnosis, treatment, and follow-up of an individual patient. Case reports also contain some demographic information about the patient (for example, age, gender, ethnic origin).

What is a patient case presentation?

A patient case presentation is a demonstration of a learner's knowledge and skills related to the management of disease states and drug therapies through application to an actual patient case. Typical Information Included in a Patient Case Presentation. 1.

What type of research is a case report?

Case reports and case series or case study research are descriptive studies that are prepared for illustrating novel, unusual, or atypical features identified in patients in medical practice, and they potentially generate new research questions.

How long should case reports 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.

Is a case report qualitative or quantitative?

qualitative dataCase studies tend to focus on qualitative data using methods such as interviews, observations, and analysis of primary and secondary sources (e.g. newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

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.

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.

What is case study in medical?

It is a well-established empirical research approach that illuminates a stand-out case of a subject or a group of subjects. In the end, it seeks to introduce new information for the understanding of the nature of a disease or medical condition in the context of someone who has lived it. 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.

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.

Why are case studies important?

However, case studies offer a comprehensive and exhaustive treatment on a complicated subject matter in a real-life setting. This research method lets you gain an appreciation for a concept beyond what cold, hard facts can provide. There is no single approach to science and knowledge.

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.

How to know if a case is appropriate for reporting?

Once you have a potential case, how would you know if this is an appropriate for reporting or not? Especially if you are a novice physician, once you encounter a possible case and you are suspecting if this patient fulfills one of those criteria which are described in Table 1. The first step is a high index of suspicion; keep your eyes open for every case, once you suspect a case then ask your colleagues either directly or in a group related to the same discipline, locally, to confirm that this could be a case report. The next step would be asking an expert from the national or international medical community about this case scenario, get their opinion and feedback, including the appropriateness of reporting this case. Once the feedback is positive, perform extensive literature search, through PubMed, Embase, Google Scholar, and databases for case reports to ensure that you retrieve all available information on this topic. Do not forget to look at popular case reports which are not indexed in PubMed and read through previously published case reports that will enhance your understanding of the subject and gives you a general scaffold to prepare your own report.

What is a case 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. Although case reports are considered the lowest in the hierarchy of evidence-based practice in the medical literature [Figure 1], it provides essential information for unfamiliar events and shared individual experiences, for better understanding and optimizing patient care. This approach might generate an idea or hypothesis, but it will not be confirmed unless we conduct further confirmatory quantitative experimental or observational study designs such as clinical trials or cohort studies. Despite that, case report provides the medical community with information which cannot be picked up by any other designs. Just to name a few, in 1819, James Parkinson published a case report entitled “An essay on the shaking palsy”[6] and lead to the discovery of Parkinson's disease. And in 1981, a case report was published in the literature as “Preliminary communication on extensively disseminated Kaposi sarcoma in a young homosexual man”[7] few years later, HIV from this case report was discovered. Furthermore, in 2012, Ali Zaki reported an article in New England Journal of Medicine titled “Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia” which ultimately, lead to the discovery of Middle East Respiratory Syndrome Coronavirus.[8] All those previous examples show how important is case report in the advancement of medical practice. The case report might be in the tail of the hierarchy of evidence-based medicine but if properly selected and appropriately reported it might stand a better chance of publication in high impact journals than even a clinical trial.

How many authors are allowed in a book?

2. Authors name: Should not exceed more than six authors

How many words should a 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.[3] If a shorter version is required by the journal, then you can always edit or trim off the discussion section of your article. The general format adopted for most case reports is detailed in the following subsection and summarized as a checklist in Table 2.

How long to wait to write a case report?

Give the case an appropriate time frame in the course of the disease to observe the development over time. Wait for 6 months during multiple visits, before you start writing a case report to allow adequate time to complete the clinical course.

What is a clinical case report?

The clinical case report has been an integral part of medical literature throughout history. The oldest example of a preserved clinical case in medical literature is a text from an ancient Egyptian papyrus dating from the 16thto the 17thdynasty, 1600 BC, addressing the management of dislocated jawbone.[5] From Hippocratic case histories, “Epidemics” 400 BC, through Galenic case reports, in the second century AD, case reports were usually used to tell other doctors or colleagues about interesting cases they have encountered. Muslim scholars have reported case histories as well, particularly, Abu Bakr Mohamed Ibn Zakariya Al-Razi (865–929 AD), where he left a large collection of case reports in his 25-volume medical encyclopedia “Kitab Al-Hawi.”[5]

Why is case report important?

Case report, as a research design, describes important scientific observations that are encountered in a clinical setting to expand our knowledge base. Preparing a case report is far easier than conducting any other elaborative research design. Case report, with its main components, should be focused and delivers a clear message. In this article, the key components of a case report were described with the aim of providing guidance to novice authors to improve the quality of their reporting.

Why are case studies not an instrument for generalizing findings?

Recommendation: Case studies are not an instrument for generalizing findings because the data is non-representative of a wider population.

What is the introduction section of a case study?

Introduction: This section briefs the reader about the topic of the study. It includes the patient’s profile, medical plight, related literature review, as well as the background of the entire case.

What is an abstract in a case study?

Some cases include an abstract in their study. Abstract, on the other hand, is a summary of the research. Method: This page presents the research design and the approach that the researchers took. The case study approach is often in the form of surveys, interviews, and questionnaires.

What is a case study?

A rose by any other name smells just as sweet. Case studies are a versatile research method that is useful in multiple domains of research. Its naturalistic design enables researchers to view a subject in its ecosystem, with less disruption, unlike experimental research.

Why do we use case studies in social science?

As a matter of fact, this research strategy originated from the medical sciences as a retrospective investigation of the patients’ medical plights. Case studies are an informed plunge into an interesting situation involving a person, group, or community. They can explore and explain correlation and causation between phenomena and theories. They can also offer insights into rooms for improvement with current practice.

What is the decision for a research method?

The decision for a research method comes down to what you want to get from the study. Before proceeding with your investigation, you should establish the objectives of the project. This step will help you from going astray during the conduct. Defining the direction of the study helps save time and resources as well.

Can you do case studies?

You can do case studies in an attempt to answer a lot of questions. However, it’s not always the appropriate approach to a problem. Maybe the query is better dealt with with an experimental research design. Do not mistake the versatility of the method as a cure-all alternative that you think will cost you less work.

What should be included in a short acknowledgement?

Acknowledgements. A short acknowledgements section should mention funding support or conflicts of interest, if applicable.

How many paragraphs should a patient share their perspective?

The patient should share their perspective on the treatment (s) they received in one to two paragraphs. 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.

What is follow up and outcomes?

Follow-up and outcomes: describe the clinical course of the episode of care during follow-up visits including (1) intervention modification, interruption, or discontinuation; (2) intervention adherence and how this was assessed; and (3) adverse effects or unanticipated events. Regular patient report outcome measurement surveys such as PROMIS® may be helpful.

How many paragraphs should a conclusion be?

The conclusion, usually one paragraph, offers the most important findings from the case without references.

Is it easier to write sections of a case report in a different sequence than the order in which the sections?

Know that it is easier to write the sections of a case report in a different sequence than the order in which the sections appear in a published case report.

Is it easy to write a case report?

Writing a case report accurately and transparently is not easy. We provide online training in writing case reports at Scientific Writing in Health and Medicine (SWIHM) which includes access to CARE-writer, an online app that can be used to write case reports or case report preprints.

Can you submit a case report to a scientific journal?

Follow author guidelines and journal submission requirements when writing and submitting your case report to a scientific journal. You may wish to contact the journal before submitting your manuscript. (Download a partial list of journals that accept case reports.) Journals that do not explicitly accept case reports may publish case reports as components of other articles. Online training in writing case reports is available from Scientific Writing in Health and Medicine (SWIHM).

How does patient participation affect health care?

We review the origins of patient participation, discuss the published evidence on its efficacy, and summarize the factors influencing its implementation. Patient-related factors, such as acceptance of the new patient role, lack of medical knowledge, lack of confidence, comorbidity, and various sociodemographic parameters , all affect willingness to participate in the health care process. Among health care workers, the acceptance and promotion of patient participation are influenced by other issues, including the desire to maintain control, lack of time, personal beliefs, type of illness, and training in patient-caregiver relationships. Social status, specialty, ethnic origin, and the stakes involved also influence patient and health care worker acceptance. The London Declaration, endorsed by the World Health Organization World Alliance for Patient Safety, calls for a greater role for patients to improve the safety of health care worldwide. Patient participation in hand hygiene promotion among staff to prevent health care—associated infection is discussed as an illustrative example. A conceptual model including key factors that influence participation and invite patients to contribute to error prevention is proposed. Further research is essential to establish key determinants for the success of patient participation in reducing medical errors and in improving patient safety.

Why is patient participation important?

Because patient participation has been shown to improve decision making and treatment of chronic diseases, it is reasonable to speculate that it could also help prevent medical errors,4,73,86-90although considerably less evidence exists for this potential application. In addition, a major initiative to enlist patients in error prevention may require that the public be reassured of the legitimacy of such an endeavor, which otherwise could be perceived at first glance as a way to police the health care worker or as putting inappropriate responsibility on an already weakened and vulnerable individual.91

How can health care workers maintain control?

Health care workers can maintain control through various means. Asking closed-ended questions limits the possibility for discussion and reduces the patient to submissiveness.33Limiting the depth and amount of information given to the patient reduces his or her autonomy33and is associated with less participation.15Health care workers can also establish their power by creating and perpetuating patient uncertainty about his or her illness, as this extract of an interview demonstrates: “Patients don't know what is happening, medical-wise….This way we have the control and it makes our job easier.”33Moreover, health care workers can limit patient participation by using authoritative language, veiled orders (eg, “you should,” “it is necessary that…”), and condescending terms such as “be good” and “be cooperative.”81

What is patient participation?

Patient participation is a complex concept and arises from the widespread consumer movement of the 1960s that affirmed the consumer's right to safety, the right to be informed, the right to choose, and the right to be heard.1During the past few years, patient participation has been increasingly recognized as a key component in the redesign of health care processes and successfully applied to some aspects of patient care, notably the decision-making process and the treatment of chronic illness. Recently, increasing patient participation has been recommended to improve patient safety. The World Health Organization (WHO) World Alliance for Patient Safety is actively highlighting the role that patients and their families could play in the improvement of health care.2However, this field of patient participation has not been widely researched thus far.

Why are medical errors preventable?

Most medical errors are preventable96and are due to a convergence of multiple contributing factors,89such as deficient processes, poor technique, inappropriate environment, failing equipment, and deficient management. Analysis of the various causes of medical errors shows that patients could help prevent many of these by intervening at various levels, and we list some examples in Table 4. Importantly, patients can participate as individuals and by acting as a group or as experts.

Do primary care physicians have more patient participation than specialists?

Primary care physicians have been linked to allowing more patient participation than specialists in most,60,69but not all,71studies, and cardiologists allow less patient participation than other specialists.69Furthermore, nonwhite physicians were less likely to encourage participation, independent of their specialty or the volume of their practice.69Physician sex15,60,69and age15,60,61do not seem to influence patient participation.

Does disease limit patient participation?

Disease and comorbidity can limit patient participation. In a study that attempted to measure preferences for participation in decision making, patients were more likely to prefer a passive role compared with their companions.36The desire to participate in decision making and to be involved in the treatment process is inversely proportional to the patient's disease severity in most,20,37-40but not all,24conditions.

What is PHI in healthcare?

This is known as safe harbor de-identification.

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 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:

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.

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 is a clinical case report?

A clinical case report or case study is a means of disseminating new knowledge gained from clinical practice. Medical practitioners often come across patient cases that are different or unusual such as a previously unknown condition, a complication of a known disease, an unusual side effect or adverse response to a mode of treatment, ...

What is a good case report?

According to Charles Young, Editor-in-chief of the journal Clinical Case Reports, a good case report is considered to be one that has a clear message, can be generalized, and is relevant to many other clinicians.

Why do doctors use case studies?

Case studies are a vehicle for doctors around the world to share their experiences with handling challenging patient cases. These can be valuable sources of information and guidance for clinical practitioners when faced with puzzling or challenging conditions in patients they attend to.

What is a young researcher's guide to writing a clinical case report?

A young researcher's guide to writing a clinical case report. Today, young researchers wish to start publishing articles early on in their career. However, they are often unsure of what type of article they wish to write and how to approach this task.

What are the sections of a case?

Case: This section provides the details of the case in the following order: 1 Patient description 2 Case history 3 Physical examination results 4 Results of pathological tests and other investigations 5 Treatment plan 6 Expected outcome of the treatment plan 7 Actual outcome

How many words should an abstract be in a case study?

Abstracts of case studies are usually very short, preferably not more than 150 words.

What is the most important part of a case report?

Discussion: This is the most important part of the case report; the part that will convince the journal that the case is publication worthy. This section should start by expanding on what has been said in the introduction, focussing on why the case is noteworthy and the problem that it addresses.

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 .

Does a case report need to be reviewed by the IRB?

Although a single case report involving up to three (3) patients may not require IRB review, those conducting such activities should be aware that certain HIPAA Privacy Rule provisions may apply and ethical concerns can arise if identifiable information is published. The use of protected health information to prepare a case report does not require IRB review for HIPAA Privacy Rule purposes. However, anyone who wishes to publish information that includes HIPAA identifiers or may identify the patient because of a description of a unique disease, condition, or outcome will need to obtain from the patient a signed HIPAA authorization using the Authorization for Disclosure of Medical Information for Publication or Conference Presentation form. This authorization does not need to be submitted to the IRB for review, but consultation with the UW-Madison HIPAA Privacy Officer is recommended. Additionally, those publishing case reports are strongly encouraged to obtain consent from any patients about whom information will be published. In the case of deceased individuals, consent might be obtained from the next of kin.

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.

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.

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

A Case For Case Studies

Case Study Templates

Sorting Medical Enigmas

Writing A Case Study

• Patient case studies describe situations and conditions that are not common to the field. They can generate new research questions and keep the research vessel anchored to our needs. In preparing your case study, these are a few things that you have to remember.

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