patient profile case report example

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.

What is the patient profile in the medical record?

Had she gone home to call you in the morning, as she wanted, she undoubtedly would have died in her sleep.'" The patient profile is the opening statement in the patient's record. It usually consists of a brief narrative about the patient's way of life:

How to write a patient case analysis?

Your patient case analysis is an investigation of a medical plight or case. When you present your findings, you have to balance the description of the situation and the detailing of the analyses. You have to illustrate how and why you came to a conclusion by providing the necessary background information.

How do you write an abstract for a patient case report?

Summary: The abstract of a patient case report should succinctly include the four sections of the main text of the report. The introduction section should provide the subject, purpose, and merit of the case report.

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...•

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.

How do you write a patient case assignment?

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 personal history of a case study?

When thinking of writing your own case study, consider these eight steps to help get you started:Gather information to create a profile for a subject. ... Choose a case study method. ... Collect information regarding the subject's background. ... Describe the subject's symptoms or problems. ... Analyze the data and establish a diagnosis.More items...•

What is included in HPI?

History of Present Illness (HPI): A description of the development of the patient's present illness. The HPI is usually a chronological description of the progression of the patient's present illness from the first sign and symptom to the present.

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.

What is a case study example?

Prospective case study methods are those in which an individual or group of people is observed in order to determine outcomes. For example, a group of individuals might be watched over an extended period of time to observe the progression of a particular disease.

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.

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 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.

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.

What should case history include?

Typical Information Contained in Case Histories In any case, some of the most common types of information often included in case histories are as follows: Basic Statistical Data (Client's name, age, sex, address, phone number, occupation, marital status, and client ID number) Client's History of Services.

What are the essential components of a patient profile?

For a single site and for each patient, Patient Profiles displays detailed patient information, a comprehensive medical history, and a graphical profile listing in Gantt and line charts; “Visits”, “Adverse Events”, “Concomitant Medication”, and “Laboratory Measurements”.

What is case history in medical terms?

a record of a person's health, development, or behaviour, kept by an official such as a doctor: The report was written after analysing data from the case histories of thousands of patients. Official documents.

What is case history in hospital?

The medical history, case history, or anamnesis (from Greek: ἀνά, aná, "open", and μνήσις, mnesis, "memory") of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information, with the aim of obtaining ...

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 the duty of a patient to fill out a questionnaire?

The person whose duty it is to instruct the patient in how to fill out a questionnaire must be sure to stress the importance of the information to the patient so that the form will be completed with sincerity. The patient should be assured that all information will remain in confidence.

What is the social history of a patient?

The patient's social history relates to where the patient lives, marital status, number and ages of children, type of work and work environment, smoking and drinking habits, activity excesses and inhibitions.

How does a patient's previous experiences with doctors affect his perception of every doctor?

A patient's previous experiences with doctors affect his perception of every doctor. A doctor's reaction to a patient of a certain age, sex, lifestyle, or ethnic group can influence his clinical decisions. Such factors should not be a part of health care; but they are, because patients and doctors are human.

What is the purpose of clinical records?

Good records safeguard the quality of these functions. Clinical records concern the health-care aspects of the practice.

What is the first step in logical health care?

To be aware of the patient's problems is the first step in logical health care. The second step is to have systematically developed complete records of the patient's problems and the care administered to monitor progress.

Can a doctor identify with a patient's story?

The doctor may be able to identify with a patient's story, but his experience can never be exactly similar. The doctor's mental image of the patient might contain information that is not in the records. In the same token, the records might contain facts that have been forgotten by the doctor.

Can an acutely ill patient be confronted with a questionnaire?

An acutely ill patient is far too disturbed to be confronted with a printed form. Many doctors feel that a questionnaire should be presented to the patient only after the initial history has been obtained and a positive rapport has been established between doctor and patient.

On this page

This is a fictitious case that has been designed for educative purposes.

Background

Mrs Beryl Brown (01/11/30) is an 85 year old woman who was admitted to the Hume Hospital by ambulance after being found by her youngest daughter lying in front of her toilet. Her daughter estimates that she may have been on the ground overnight.

Social history

I understand that Mrs Brown has been residing in her own home, a two story terrace house, in Melbourne for almost 60 years. She has lived alone since her husband died two years ago following a cardiac arrest. She has two daughters. The youngest daughter Jean has lived with her for the past year, after she lost her job.

Current function

Mrs Brown has a history of Alzheimer’s disease; type II diabetes – insulin dependent; hypertension; high cholesterol and osteoarthritis. She has had two recent admissions to hospital for a urinary tract infection and a fall in the context of low blood sugars.

The current risks

Mrs Brown is at high risk of experiencing falls. She has reduced awareness of the left side of her body and her ability to plan and process information has been affected by her stroke. She is now requiring one to two people to assist with all her tasks of daily living and she lacks insight into these deficits.

Attempts to trial least restrictive options

We have convened two family meetings with Mrs Brown, both her daughters and several members of the multi-disciplinary team. The outcome of the first meeting saw all parties agree for the ward to provide personalised carer training to Jean with the aim of trialling a discharge home.

Recommendation

The treating team believe they have exhausted all least restrictive alternatives and that a guardianship order is required to make a decision on Mrs Brown’s discharge destination and access to services. The team recommend that the Public Advocate be appointed as Mrs Brown’s guardian of last resort.

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 the purpose of the status section in a medical report?

In this section, you will provide the patient’s information, such as medical history, and give the current patient’s diagnosis, condition, and treatment. Always remember to write down all the relevant information about the patient.

What is case study nursing?

A nursing case study is a detailed study of an individual patient. Through this type of research, you can gain more information about the symptoms and the medical history of a patient.

What should you explain in a nursing observation?

You should explain each observation that you have collected based on the vital signs and test results. You will also explain each nursing diagnosis that you have identified and determine the proper nursing care plan for the patient. 3. The Current Care Plan and Recommendations.

What is the current care plan?

The Current Care Plan and Recommendations. Describe the appropriate care plan that you can recommend to the patient based on the diagnosis, current status, and prognosis in detail, including how the care plan will affect his or her life quality.

Do you need to reassess a nursing case study?

You may need to reassess the patient depending on his progress, and the care plan may be modified based on the reassessment result. Carrying out a nursing case study can be a delicate task since it puts the life of a person at stake. Thus, it requires a thorough investigation.