medical case study format

Medical Case Study Template

Utilize our Medical Case Study Template for systematic documentation and analysis of patient cases, enhancing learning and clinical practice.

By Emma Hainsworth on Jul 02, 2024.

Fact Checked by Ericka Pingol.

What is a Medical Case Study Template?

A Medical Case Study Template is a systematic tool used primarily by healthcare professionals and students to document, analyze, and present individual patient cases. It serves as a structured guide, ensuring that all critical aspects of the case are captured and discussed in a standardized format. This includes patient information, clinical history, diagnostic assessments, treatments, and outcomes.

The template typically starts with a title and a brief abstract summarizing the case. It progresses through detailed sections covering patient demographics, symptoms, examination findings, and the results of any diagnostic tests. Treatment plans and their outcomes are also meticulously documented.

One of the key purposes of this template is educational. It facilitates learning by providing a comprehensive overview of real-life clinical scenarios, encouraging critical thinking and analysis. It's also used in medical research and literature to share clinical experiences and insights, contributing to the broader medical community's understanding of various conditions and treatments.

Using a Medical Case Study Template ensures a thorough and uniform approach to case documentation, which is essential for effective learning, discussion, and advancement in medical practice. It emphasizes the importance of detail and accuracy in clinical reporting, enhancing both educational value and patient care.

PDF Template

Example pdf, printable medical case study template.

Download this Medical Case Study Template used primarily by healthcare professionals and students to document, analyze, and present individual patient cases.

How does it work?

Here's a step-by-step guide to accessing and using our Medical case study template:

Step 1: Access and download the Medical Case Study Template

Click the link on this page to download and access the Medical Case Study Template. The template is available in a user-friendly PDF format, allowing for easy digital viewing and interaction.

You can print the template if a physical copy is preferred for note-taking or group discussions. This is especially useful in educational settings or during team meetings.

Step 2: Understand the structure of the template

Review the template to understand its various sections, which include patient information, clinical history, diagnosis, treatment, and outcome.

Note the specific details required in each section, such as demographic data, symptoms, test results, and follow-up care. Understanding these components is crucial for consistency and comprehensiveness in case documentation.

Step 3: Utilize the template for case documentation

Use the template to systematically record all relevant details of a patient case. This might be for educational purposes, research, or clinical documentation.

Regularly update the template with new information or follow-up details. This is important for tracking the case's progression and observing treatments' effectiveness.

Keep in mind that each patient case is unique. The template should be adaptable to accommodate the specificities of different medical scenarios.

Step 4: Review and share the documented case

Use the documented case for peer discussions, educational sessions, or team reviews. The structured format of the template facilitates easy sharing and collaborative analysis.

Encourage feedback on the documented case to enhance learning and improve clinical practices. The template can be a tool for reflective practice and continuous professional development.

By following these steps, healthcare professionals, educators, and students can effectively use the Medical Case Study Template for a range of purposes. This resource is invaluable for documenting individual cases and as a tool for education, research, and collaborative learning in the medical field.

Medical Case Study Example (sample)

We have provided a comprehensive example as a downloadable PDF to help users effectively utilize the Medical Case Study Template. This sample case study is a practical guide, demonstrating how to document and analyze a clinical case in a structured and detailed manner. It is especially useful for medical professionals, educators, and students in the healthcare field.

The Medical Case Study PDF Example, readily available for download and review, showcases the practical application of the case study template in a real-world clinical setting. The example features a case study highlighting how to systematically record patient information, clinical history, diagnostic assessments, treatment plans, and outcomes.

You can access this valuable resource by either previewing the sample provided below or clicking the "Download Example PDF" button. 

Download this Medical Case Study Template example:

When would you use this Template?

The Medical Case Study Template is an invaluable resource primarily used by healthcare professionals, medical students, and educators in various clinical and educational settings. Its application is particularly relevant and beneficial in several key scenarios.

Clinical education and training

Medical educators often use this template to teach students about real-life medical cases. It provides a structured approach to case analysis, encouraging students to examine all aspects of patient care, from diagnosis to treatment and follow-up. This methodical approach is crucial in developing critical thinking and diagnostic skills.

Peer learning and discussion

The template is used among healthcare professionals as a basis for case discussions, often in grand rounds or peer review meetings. It allows practitioners to present complex cases to colleagues, fostering collaborative analysis and discussion. This shared learning experience can lead to improved patient care strategies and a deeper understanding of rare or challenging cases.

Research and case reporting

When documenting unique or particularly instructive cases for medical research or publication, the Medical Case Study Template provides a comprehensive format. It ensures that all relevant details are systematically presented, making the case valuable for the wider medical community. This is especially important when contributing to medical journals or databases.

Quality improvement initiatives

In quality assurance and improvement activities within healthcare settings, this template can be used to analyze cases that highlight systemic issues or successes. It aids in identifying areas for improvement in patient care processes and protocols.

Personal professional development

For individual healthcare practitioners, the template serves as a tool for reflecting on challenging cases, allowing for self-assessment and continuous professional development.

Benefits of using this template ? 

Using a Medical Case Study Template offers several significant benefits:

• Standardized documentation: The template provides a uniform structure for documenting patient cases. This standardization is crucial for ensuring that all relevant details are consistently recorded and easy to find, which is particularly beneficial when multiple healthcare professionals review cases.
• Enhanced educational value: For medical students and trainees, the template is an educational tool that promotes a thorough understanding of clinical cases. It encourages a holistic view of patient care, encompassing diagnosis, treatment, and follow-up, and helps in developing critical thinking and analytical skills.
• Improved communication: When discussing patient cases with peers or in academic settings, the template aids in clear and concise communication. It ensures that all necessary information is presented in an organized manner, facilitating better understanding and discussion among medical professionals.
• Quality of care and patient safety: By systematically documenting and reviewing patient cases, healthcare providers can identify trends, successes, and areas for improvement in treatment protocols. This can lead to enhanced patient safety and overall quality of care.
• Facilitates research and publication: The template is invaluable for practitioners looking to publish case reports in medical journals. It ensures that the case is documented in a comprehensive and systematic manner, meeting the standards required for academic and research publications.
• Professional development: Regular use of the template encourages practitioners to reflect on their clinical practice, helping them to identify areas for professional growth and development.
• Consistency in case analysis: The template provides a consistent framework for analyzing and discussing patient cases. This consistency is essential for comparative analysis and for understanding the nuances of different cases.
• Time efficiency: With a set structure in place, healthcare professionals can save time in documenting and reviewing cases, as they do not have to create a new format each time.

Why use Carepatron as your Medical Case Study app?

Carepatron is an exceptional choice for healthcare professionals looking for a Medical Case Study app, offering a blend of key features that cater to efficiency, security, and ease of use:

• Comprehensive electronic health records (EHR): Carepatron excels in organizing and maintaining detailed patient records, essential for medical case studies. The EHR system, detailed on our electronic health records page , allows for easy access and management of patient histories, treatment plans, and progress notes, ensuring all crucial data is at your fingertips.
• Streamlined practice management: The platform simplifies various administrative tasks, from scheduling appointments to billing processes. This integration ensures that healthcare professionals can focus more on patient care and less on time-consuming administrative duties.
• Secure data handling and compliance: Emphasizing the importance of data security, Carepatron ensures that all patient information is handled following strict compliance standards like HIPAA, guaranteeing confidentiality and trust.
• Flexible appointment scheduling and reminders: The platform facilitates efficient planning and management of patient appointments through its appointment scheduling feature. 

By integrating these essential features into one intuitive platform, Carepatron makes managing medical case studies more streamlined and elevates the overall quality of patient care.

Commonly asked questions

A Medical Case Study Template is a structured document used to record and analyze patient cases in a systematic and detailed manner. It helps in documenting patient history, diagnosis, treatment, and follow-up, ensuring all crucial aspects of the case are covered.

Medical professionals, including doctors, nurses, and therapists, as well as medical students and educators, can benefit from using this template. It's also useful for researchers and clinicians involved in case studies for publication or presentation.

The template ensures comprehensive documentation of patient cases, which aids in better understanding and analyzing the patient's condition and treatment outcomes. This thorough approach can lead to more informed and effective patient care strategies.

Related Templates

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How to Write a Medical Case Study Report

Last Updated: April 18, 2024 Fact Checked

This article was medically reviewed by Mark Ziats, MD, PhD and by wikiHow staff writer, Jennifer Mueller, JD . Dr. Mark Ziats is an Internal Medicine Physician, Scientist, Entrepreneur, and the Medical Director of xBiotech. With over five years of experience, he specializes in biotechnology, genomics, and medical devices. He earned a Doctor of Medicine degree from Baylor College of Medicine, a Ph.D. in Genetics from the University of Cambridge, and a BS in Biochemistry and Chemistry from Clemson University. He also completed the INNoVATE Program in Biotechnology Entrepreneurship at The Johns Hopkins University - Carey Business School. Dr. Ziats is board certified by the American Board of Internal Medicine. There are 15 references cited in this article, which can be found at the bottom of the page. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 187,998 times.

You've encountered an interesting and unusual case on your rounds, and a colleague or supervising physician says, "Why don't you write up a case study report?" If you've never written one before, that might sound intimidating, but it's a great way to get started in medical writing. Case studies always follow a standard structure and format, so the writing is very formulaic once you get the hang of it. Read on for a step-by-step guide to writing your first case study report.

What is a case study report?

• Medical students or residents typically do the bulk of the writing of the report. If you're just starting your medical career, a case study report is a great way to get a publication under your belt. [2] X Research source

• If the patient is a minor or is incapable of giving informed consent, get consent from their parents or closest relative. [4] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source
• Your hospital likely has specific consent forms to use. Ask your supervising physician if you're not sure where to get one.
• Some journals also have their own consent form. Check your target journal's author or submission information to make sure. [5] X Research source

How is a case study report structured?

• Even though the introduction is the first part of a case study report, doctors typically write it last. You'll have a better idea of how to introduce your case study to readers after you've written it.
• Your abstract comes at the top, before the introduction, and provides a brief summary of the entire report. Unless your case study is published in an open-access journal, the abstract is the only part of the article many readers will see.

• Many journals offer templates and checklists you can use to make sure your case study includes everything necessary and is formatted properly—take advantage of these! Some journals, such as BMJ Case Reports , require all case studies submitted to use their templates.

Drafting Your Medical Case Study Report

• Patient description
• Chronological case history
• Physical exam results
• Results of any pathological tests, imaging, or other investigations
• Treatment plan
• Expected outcome of treatment
• Actual outcome of treatment

• Why the patient sought medical help (you can even use their own words)
• Important information that helped you settle on your diagnosis
• The results of your clinical examination, including diagnostic tests and their results, along with any helpful images
• A description of the treatment plan
• The outcome, including how and why treatment ended and how long the patient was under your care [11] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source

• You will need references to back up symptoms of the condition, common treatment, and the expected outcome of that common treatment.
• Use your research to paint a picture of the usual case of a patient with a similar condition—it'll help you show how unusual and different your patient's case is.
• Generally, aim for around 20 references—no fewer than 15, but no more than 25. [13] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source

• Close your discussion section with a summary of the lessons learned from the case and why it's significant to consider when treating similar cases in the future.
• Outline any open questions that remain. You might also provide suggestions for future research.

• In your conclusion, you might also give suggestions or recommendations to readers based on what you learned as a result of the case.
• Some journals don't want a separate conclusion section. If that's the case for one of your target journals, just move this paragraph to the end of your discussion section.

Polishing Your Report for Submission to Publishers

• Most titles are fewer than 10 words long and include the name of the disease or condition treated.
• You might also include the treatment used and whether the outcome was successful. When deciding what to include, think about the reason you wrote the case study in the first place and why you think it's important for other clinicians to read.

• Made a significant intellectual contribution to the case study report
• Was involved in the medical care of the patient reported
• Can explain and defend the data presented in the report
• Has approved the final manuscript before submission for publication

• Keep in mind that the abstract is not just going to be the first thing people read—it will often be the only thing people read. Make sure that if someone is going to walk away having only read the abstract, they'll still get the same message they would have if they read the whole thing.
• There are 2 basic types of abstract: narrative and structured. A narrative abstract is a single paragraph written in narrative prose. A structured abstract includes headings that correspond with the sections of the paper, then a brief summary of each section. Use the format preferred by your target journal.

• Look for keywords that are relevant to your field or sub-field and directly related to the content of your article, such as the name of the condition or specific treatments you used.
• Most journals allow 4-8 keywords but check the submission guidelines of your target journal to make sure.

• Blur out the patient's face as well as any tattoos, birthmarks, or unrelated scars that are visible in diagnostic images.

• It's common to thank the patient, but that's up to you. Even if you don't, include a statement indicating that you have the patient's written, informed consent to publish the information.
• Read the journal's submission guidelines for a definition of what that journal considers a conflict of interest. They're generally the same, but some might be stricter than others. [22] X Research source

• If you're not familiar with the citation style used by your target journal, check online for a guide. There might also be one available at your hospital or medical school library.
• Medical librarians can also help with citation style and references if you run into something tricky—don't just wing it! Correct citation style insures that readers can access the materials you cite.

• It's also a good idea to get a beta reader who isn't a medical professional. Their comments can help you figure out where you need to clarify your points.
• Read a lot of case studies published in your target journals—it will help you internalize the tone and style that journal is looking for.

Submitting Your Report to Publishers

• Look into the background and reputation of journals before you decide to submit to them. Only seek publication from reputable journals in which articles go through a peer-review process.
• Find out what publishing fees the journals charge. Keep in mind that open-access journals tend to charge higher publishing fees. [26] X Research source
• Read each journal's submission and editorial guidelines carefully. They'll tell you exactly how to format your case study, how long each section should be, and what citation style to use. [27] X Research source
• For electronic journals that only publish case reports, try BMJ Case Reports , Journal of Medical Case Reports , or Radiology Case Reports .

• If your manuscript isn't suitable for the journal you submitted to, the journal might offer to forward it to an associated journal where it would be a better fit.
• When your manuscript is provisionally accepted, the journal will send it to other doctors for evaluation under the peer-review process.
• Most medical journals don't accept simultaneous submissions, meaning you'll have to submit to your first choice, wait for their decision, then move to the next journal on the list if they don't bite.

• Along with your revised manuscript, include a letter with your response to each of the reviewer's comments. Where you made revisions, add page numbers to indicate where the revisions are that address that reviewer's comments.
• Sometimes, doctors involved in the peer review process will indicate that the journal should reject the manuscript. If that's the case, you'll get a letter explaining why your case study report won't be published and you're free to submit it elsewhere.

• Some journals require you to have your article professionally copy-edited at your own cost while others do this in-house. The editors will let you know what you're responsible for.

• With your acceptance letter, you'll get instructions on how to make payment and how much you owe. Take note of the deadline and make sure you pay it as soon as possible to avoid publication delays.
• Some journals will publish for free, with an "open-access option" that allows you to pay a fee only if you want open access to your article. [32] X Research source

• Through the publishing agreement, you assign your copyright in the article to the journal. This allows the journal to legally publish your work. That assignment can be exclusive or non-exclusive and may only last for a specific term. Read these details carefully!
• If you published an open-access article, you don't assign the copyright to the publisher. The publishing agreement merely gives the journal the right to publish the "Version of Record." [33] X Research source

How do I find a suitable case for a report?

• A rare disease, or unusual presentation of any disease
• An unusual combination of diseases or conditions
• A difficult or inconclusive diagnosis
• Unexpected developments or responses to treatment
• Personal impact
• Observations that shed new light on the patient's disease or condition

• There might be other members of your medical team that want to help with writing. If so, use one of these brainstorming sessions to divvy up writing responsibilities in a way that makes the most sense given your relative skills and experience.
• Senior doctors might also be able to name some journals that would potentially publish your case study. [36] X Research source

Expert Q&A

You Might Also Like

• ↑ https://www.elsevier.com/connect/authors-update/the-dos-and-donts-of-writing-and-publishing-case-reports
• ↑ https://www.bmj.com/content/350/bmj.h2693
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686928/
• ↑ https://health.usf.edu/medicine/internalmedicine/im-impact/~/media/B3A3421F4C144FA090AE965C21791A3C.ashx
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597880/
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476221/
• ↑ https://www.springer.com/gp/authors-editors/authorandreviewertutorials/writing-a-journal-manuscript/title-abstract-and-keywords/10285522
• ↑ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597880/
• ↑ https://thelancet.com/pb/assets/raw/Lancet/authors/tl-info-for-authors.pdf
• ↑ https://jmedicalcasereports.biomedcentral.com/articles/10.1186/s13256-017-1351-y
• ↑ https://guides.himmelfarb.gwu.edu/casereports
• ↑ https://casereports.bmj.com/pages/authors/
• ↑ https://jmedicalcasereports.biomedcentral.com/articles/10.1186/1752-1947-7-239
• ↑ https://research.chm.msu.edu/students-residents/writing-a-case-report
• ↑ https://authorservices.taylorandfrancis.com/publishing-your-research/moving-through-production/copyright-for-journal-authors/#

About This Article

Medical Disclaimer

The content of this article is not intended to be a substitute for professional medical advice, examination, diagnosis, or treatment. You should always contact your doctor or other qualified healthcare professional before starting, changing, or stopping any kind of health treatment.

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To start a medical case study report, first choose a title that clearly reflects the contents of the report. You’ll also need to list any participating authors and develop a list of keywords, as well as an abstract summarizing the report. Your report will need to include an introduction summarizing the context of the report, as well as a detailed presentation of the case. Don’t forget to include a thorough citation list and acknowledgements of anyone else who participated in the study. For more tips from our Medical co-author, including how to get your case study report published, keep reading! Did this summary help you? Yes No

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Writing a Case Report

This page is intended for medical students, residents or others who do not have much experience with case reports, but are planning on writing one.  

What is a case report?  A medical case report, also known as a case study, is a detailed description of a clinical encounter with a patient.  The most important aspect of a case report, i.e. the reason you would go to the trouble of writing one, is that the case is sufficiently unique, rare or interesting such that other medical professionals will learn something from it.   

Case reports are commonly of the following categories :

- Rare diseases

- Unusual presentation of disease

- Unexpected events

- Unusual combination of diseases or conditions

- Difficult or inconclusive diagnosis

- Treatment or management challenges

- Personal impact

- Observations that shed new light on a disease or condition

- Anatomical variations

It is important that you recognize what is unique or interesting about your case, and this must be described clearly in the case report.

Case reports generally take the format of :

1. Background

2. Case presentation

3. Observations and investigation

4. Diagnosis

5. Treatment

7. Discussion

Does a case report require IRB approval?

Case reports typically discuss a single patient. If this is true for your case report, then it most likely does not require IRB approval because it not considered research.    If you have more than one patient, your study could qualify as a Case Series, which would require IRB review.  If you have questions, you chould check your local IRB's guidelines on reviewing case reports.

Are there other rules for writing a case report?

First, you will be collecting protected health information, thus HIPAA applies to case reports.   Spectrum Health has created a very helpful guidance document for case reports, which you can see here:   Case Report Guidance - Spectrum Health

While this guidance document was created by Spectrum Health, the rules and regulations outlined could apply to any case report.  This includes answering questions like: Do I need written HIPAA authorization to publish a case report?  When do I need IRB review of a case report?  What qualifies as a patient identifier?

How do I get started?

1. We STRONGLY encourage you to consult the CARE Guidelines, which provide guidance on writing case reports -  https://www.care-statement.org/

Specifically, the checklist -  https://www.care-statement.org/checklist  - which explains exactly the information you should collect and include in your case report.  

2. Identify a case.  If you are a medical student, you may not yet have the clinical expertise to determine if a specific case is worth writing up.  If so, you must seek the help of a clinician.  It is common for students to ask attendings or residents if they have any interesting cases that can be used for a case report. 

3. Select a journal or two to which you think you will submit the case report.   Journals often have specific requirements for publishing case reports, which could include a requirement for informed consent, a letter or statement from the IRB and other things.  Journals may also charge publication fees (see Is it free to publish? below)   

4. Obtain informed consent from the patient (see " Do I have to obtain informed consent from the patient? " below).  Journals may have their own informed consent form that they would like you to use, so please look for this when selecting a journal.

Once you've identified the case, selected an appropriate journal(s), and considered informed consent, you can collect the required information to write the case report.

How do I write a case report?

Once you identify a case and have learned what information to include in the case report, try to find a previously published case report.  Finding published case reports in a similar field will provide examples to guide you through the process of writing a case report.    

One journal you can consult is BMJ Case Reports .  MSU has a multi-year open access publishing agreement with the publisher BM J , and an institutional fellowship with BMJ Case Reports which allows MSU faculty, staff and students to publish in this journal for free.  See this page for a link to the journal and more information on publishing-    https://lib.msu.edu/collections/scholcomm/support

There are numerous other journals where you can find published case reports to help guide you in your writing. 

Do I have to obtain informed consent from the patient?

The CARE guidelines recommend obtaining informed consent from patients for all case reports.  Our recommendation is to obtain informed consent from the patient.  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).  Please consider this as well.  

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://casereports.bmj.com/ .  Go to "Instructions for Authors" and then "Patient Consent" to find the consent form they use.  You can create a similar form to obtain consent from your patient.  If you have identified a journal already, please consult their requirements and determine if they have a specific consent form they would like you to use.

Seek feedback

Once you have written a draft of the case report, you should seek feedback on your writing, from experts in the field if possible, or from those who have written case reports before.   

Selecting a journal

Aside from BMJ Case Reports mentioned above, there are many, many journals out there who publish medical case reports.   Ask your mentor if they have a journal they would like to use.  If you need to select on your own, here are some strategies:

1. Do a PubMed search.  https://pubmed.ncbi.nlm.nih.gov/

   a. Do a search for a topic, disease or other feature of your case report 

   b. When the results appear, on the left side of the page is a limiter for "article type".  Case reports are an article type to which you can limit your search results.  If you don't see that option on the left, click "additional filters". 

   c. Review the case reports that come up and see what journals they are published in.

2. Use JANE -  https://jane.biosemantics.org/

3. Check with specialty societies.  Many specialty societies are affiliated with one or more journal, which can be reviewed for ones that match your needs

4. Search through individual publisher journal lists.  Elsevier publishes many different medical research journals, and they have a journal finder, much like JANE  ( https://journalfinder.elsevier.com/ ).  This is exclusive to Elsevier journals.  There are many other publishers of medical journals for review, including Springer, Dove Press, BMJ, BMC, Wiley, Sage, Nature and many others.

Is it free to publish ?

Be aware that it may not be free to publish your case report.  Many journals charge publication fees. Of note, many open access journals charge author fees of thousands of dollars.  Other journals have smaller page charges (i.e. $60 per page), and still others will publish for free, with an "open access option".  It is best practice to check the journal's Info for Authors section or Author Center to determine what the cost is to publish.  MSU-CHM does NOT have funds to support publication costs, so this is an important step if you do not want to pay out of pocket for publishing

*A more thorough discussion on finding a journal, publication costs, predatory journals and other publication-related issues can be found here:   https://research.chm.msu.edu/students-residents/finding-a-journal

Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D. 2013. The CARE guidelines: Consensus-based clinical case reporting guideline development.  Glob Adv Health Med . 2:38-43. doi:  10.7453/gahmj.2013.008

Riley DS, Barber MS, Kienle GS, AronsonJK, von Schoen-Angerer T, Tugwell P, Kiene H, Helfand M, Altman DG, Sox H, Werthmann PG, Moher D, Rison RA, Shamseer L, Koch CA, Sun GH, Hanaway P, Sudak NL, Kaszkin-Bettag M, Carpenter JE, Gagnier JJ. 2017. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol . 89:218-234. doi: 10.1016/j.jclinepi.2017.04.026  

Guidelines to writing a clinical case report. 2017. Heart Views . 18:104-105. doi:  10.4103/1995-705X.217857

Ortega-Loubon C, Culquichicon C, Correa R. The importance of writing and publishing case reports during medical education. 2017. Cureus. 9:e1964. doi:  10.7759/cureus.1964

Writing and publishing a useful and interesting case report. 2019. BMJ Case Reports.  Link to document

Camm CF. Writing an excellent case report: EHJ Case Reports , Case of the Year 2019. 2020. European Heart Jounrnal. 41:1230-1231.  https://doi.org/10.1093/eurheartj/ehaa176  

*content developed by Mark Trottier, PhD

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How to write a medical case report

• Related content
• Peer review
• Seema Biswas , editor-in-chief, BMJ Case Reports, London, UK ,
• Oliver Jones , student editor, BMJ Case Reports, London, UK

Two BMJ Case Reports journal editors take you through the process

This article contains...

- Choosing the right patient

- Choosing the right message

- Before you begin - patient consent

- How to write your case report

- How to get published

During medical school, students often come across patients with a unique presentation, an unfamiliar response to treatment, or even an obscure disease. Writing a case report is an excellent way of documenting these findings for the wider medical community—sharing new knowledge that will lead to better and safer patient care.

For many medical students and junior doctors, a case report may be their first attempt at medical writing. A published case report will look impressive on your curriculum vitae, particularly if it is on a topic of your chosen specialty. Publication will be an advantage when applying for foundation year posts and specialty training, and many job applications have points allocated exclusively for publications in peer reviewed journals, including case reports.

The writing of a case report rests on skills that medical students acquire in their medical training, which they use throughout their postgraduate careers: these include history taking, interpretation of clinical signs and symptoms, interpretation of laboratory and imaging results, researching disease aetiology, reviewing medical evidence, and writing in a manner that clearly and effectively communicates with the reader.

If you are considering writing a case report, try to find a senior doctor who can be a supervising coauthor and help you decide whether you have a message worth writing about, that you have chosen the correct journal to submit to (considering the format that the journal requires), that the process is transparent and ethical at all times, and that your patient is not compromised in your writing. Indeed, try to include your patient in the process from the …

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• v.11(12); 2019 Dec

Developing a Beginner’s Guide to Writing a Clinical Case Report: A Pilot Evaluation by Junior Doctors

Samson o oyibo.

1 Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, GBR

Introduction

Writing a case report increases one’s knowledge about a particular disease condition, demonstrates intellectual curiosity and commitment to scientific inquiry and the ability to follow through on scholarly projects. Despite several articles and journal-specific instructions published concerning case report writing, none have been evaluated by their intended audience. The aim of this study was to get junior doctors to evaluate an online presentation as part of the process of developing a beginner’s guide to writing a clinical case report.

Materials and methods

In response to our previous studies an online presentation concerning how to write a clinical case report was provided for junior doctors. Junior doctors were invited by email to look at the online presentation and complete an online evaluation form thereafter. The questions were adapted from the Evaluation Form for Teaching and Presentations provided by the Joint Royal Colleges of Physicians Training Board. Data was analysed both quantitatively and qualitatively.

Sixty-five doctors looked at the presentation and completed the online evaluation form. All agreed that the objectives of the presentation were identified and met. Sixty-four (98.5%) agreed that it was effective and clear. Sixty percent indicated that they found the information and instructions useful. An additional 13.85% found the whole presentation useful without specifying any aspect. Eight percent found the summary slide useful, 4.62% found the case selection criteria slide to be useful and 4.62% found the permission and patient consenting slide useful. Twenty percent would like the inclusion of examples of good abstracts and case reports, 13.85% would like more teaching sessions, and 13.85% would like improvements to the slide-presentation format. Overall, 64 junior doctors (98.46%) remarked that the presentation was good, very good or excellent.

Conclusions

This study has demonstrated the importance of evaluation of teaching material by junior doctors while developing a beginner’s guide to writing a clinical case report. Once the above action points and limitations have been taken into account, further repeat evaluations by junior doctors need to be undertaken while developing a robust beginner’s guide to writing a clinical case report.

Having an article published in a peer-reviewed medical journal is important for career progression in several medical specialties. Although enhancement of their curriculum vitae has been cited as a motivation to getting published, a keen interest in the subject is a more important reason stated by doctors [ 1 ]. Writing up a case report increases one’s knowledge about a particular disease condition, demonstrates intellectual curiosity and commitment to scientific inquiry and the ability to follow through on scholarly projects [ 2 ].

In a previous study, we demonstrated that junior doctors feel that medical article publishing is an effective teaching method but little was done to help them bridge the gap between getting an interesting case and getting published [ 3 ]. In a follow-up study, we highlighted the importance of establishing a medical article publishing club for junior doctors based on action points from the previous study. Junior doctors said that the medical article publishing club contributed to learning, education and publishing skills [ 4 ].

In response to action points from the above-mentioned studies an online PowerPoint presentation was provided for junior doctors on “a guide to writing a clinical case report”. The main objective of this study was to obtain junior doctors’ evaluation of the online presentation, with the ultimate aim of making improvements and developing a robust and user-friendly guide to writing clinical case reports.

The online presentation

As an action point to a previous study an online PowerPoint presentation of “a guide to writing a clinical case report” was made for junior doctors to aid them in writing clinical case reports. This consisted of 18 PowerPoint slides starting from the title slide to the bibliography slide. This presentation was made available on our institution’s educational website for all junior doctors to use. The PowerPoint presentation is shown in Figure ​ Figure1 1 .

Study participants

Junior doctors in our healthcare institution were invited by email to look at the online PowerPoint presentation and complete an online evaluation form thereafter. There was also the facility to download the presentation. Invited doctors were given four weeks to respond while a reminder invitation email was sent every week for the same four-week period.

Study design

As part of the email, a web-based evaluation form was administered to junior doctors so that they could evaluate the online PowerPoint presentation after going through it. The evaluation form distribution and data collection were carried out over a four-week period. Ethics approval was sought through the Research & Development department of our institute. This study did not require ethical approval on the account of it being registered with our Quality, Governance and Compliance Department as a Quality of Education Improvement Project. Participants were assured of strict anonymity and confidentiality during this study.

Evaluation questionnaire

The evaluation questionnaire was prepared online using SurveyMonkey [ 5 ]. The questions were adapted from the Evaluation Form for Teaching and Presentations provided by the Joint Royal Colleges of Physicians Training Board [ 6 ]. The questionnaire contained six questions: (1) were the objectives of the online presentation identified, (2) were the objectives met, (3) was the delivery of the presentation effective and clear, (4) what aspects of the presentation was useful, (5) any suggestions for improvement, and (6) overall, what is your evaluation of the online presentation. Questions 1-3 required a “yes” or “no” answer. Questions 4-5 were open-ended questions requiring input into a comment box. Question 6 required an answer from “very bad”, “poor”, “fair”, “good”, “very good” or “excellent”. A web-link to the questionnaire was sent via email to participants.

Data analysis

The responses to questions 1, 2, 3, and 6 were analyzed and presented as whole numbers (and percentages). The answers to questions 4 and 5 were transcribed verbatim and analyzed qualitatively by the process of thematic analysis [ 7 , 8 ]. The data was reviewed for initial codes, subthemes and subsequently developed themes related to what was found useful and suggestions for improvement. The raw data, subthemes and themes were continuously reflected upon to ensure credibility and trustworthiness of this survey [ 9 ].

There were 65 respondents to the invitation emails. Therefore, 65 junior doctors looked at the presentation and completed the online evaluation form.

Objectives, clearness and effectiveness

All 65 respondents (100%) agreed that the objectives of the presentation were identified. All 65 respondents (100%) agreed that the objectives of the presentation were met. Sixty-four respondents (98.5%) agreed that the presentation was effective and clear. This is shown in Table ​ Table1 1 .

Useful aspects and suggestions for improvement

The answers to questions 4 and 5 were analysed thematically. The raw data (answers to both questions along with the thematic analysis) used to support the findings of this study has been deposited in the Harvard Dataverse and is freely accessible [ 10 ]. The main themes derived from the analysis are presented here.

Question 4 - What Aspect of the Presentation Was Useful?

All respondents answered question 4, and several major themes emerged from the thematic analysis. Thirty-nine respondents (60%) indicated that they found the information and instructions provided in the presentation useful (e.g., they highlighted the stepwise approach, breakdown, clear, concise and systematic structure of the information provided). Nine respondents (13.85%) indicated they found the whole presentation useful without specifying any aspect. Five respondents (7.69%) indicated that they found the summary slide useful. Three respondents (4.62%) indicated that they found the case selection criteria slide to be useful. A similar number of respondents (4.62%) indicated that they found the permission and patient consenting slide useful. One respondent particularly found the abstract slide useful. Two respondents indicated that the subject/topic was useful. Two respondents made an abbreviated text comments which could not be deciphered while one respondent indicated that the presentation was “a bit vague”.

Question 5 - Any Suggestions for Improvement?

Sixty-two respondents answered question 5, and several major themes emerged from the thematic analysis. Thirteen respondents (20%) indicated that they would like the inclusion of examples of good abstracts and case reports. Nine respondents (13.85%) indicated that they would like more presentations and teaching sessions (e.g., workshop sessions, online sessions and circulation of the presentation to more junior doctors and medical students). Nine respondents (13.85%) indicated that the slide-presentation format could be improved (e.g., add more colour, make the slides more interactive, less crowded, less rushed, shorter presentation). Thirty respondents (46.15%) indicated “nil” or “none” in response to the question “any suggestions for improvement”. Two respondents just gave praises (e.g., good job, well done), one respondent made an abbreviated text comment which could not be deciphered, and another left that question blank.

Overall evaluation of the presentation

Sixty-four respondents (98.46%) remarked that the presentation was good, very good or excellent. One respondent remarked that the presentation was poor. This is shown in Table ​ Table2 2 .

Formal training and adequate mentorship are key ingredients required to help junior doctors with writing and presenting case reports. The importance of lack of these factors has been highlighted in a previous study looking at the perceptions of fourth-year medical students on writing case reports [ 11 ]. In this study, medical students indicated that lack of formal training and lack of mentorship were significant barriers to writing and presenting cases. There are several journal-specific guides and instructions on how to write clinical case reports but despite this, junior doctors still find it difficult to write up a case report. This fact emphasizes the importance of mentorship and training, which could be provided by a curriculum-based medical article publishing club or forum, which should include an easy-to-follow guide to writing case reports for junior doctors. While developing such a guide it is important that there is continuous evaluation by the junior doctors. Evaluation should be a continuous and periodic process, as it helps teachers and learners to improve the teacher-learner process.

There are several articles and journal-specific instructions published concerning writing clinical case reports but there is scarcity of reports of evaluation of these published guides and instructions by their intended audience. A guide to writing case reports directed at junior doctors in a user-friendly format and evaluated by junior doctors may go a long way in helping junior doctors write up clinical case reports. Such a guide can be included in the junior doctors’ teaching curriculum alongside an adequate mentorship program.

Action points from this pilot study

This study has demonstrated the importance of evaluation of teaching material by the intended learners, the junior doctors in this case. Junior doctors found the PowerPoint presentation about a “guide to writing a clinical case report” useful. In particular: the layout of the instructions, the information about permission and patient consenting, the information about case selection criteria, and the summary slide at the end of the presentation. The junior doctors also suggested ways of improving the presentation, namely, inclusion of examples and illustrations of good abstracts and case reports, adding colour to the presentation and making it more interactive and providing more teaching sessions and presentations on the topic of writing clinical case reports. These factors will be taken into account while making the improvements to this guide.

Limitations

This study has some limitations that should be acknowledged. First, this study assumes that everyone who looked at the presentation went on to complete the evaluation form. We have no way of knowing how many junior doctors looked at the presentation without going on to complete the online evaluation form. There are various forms of page-view/download counters that can be used to access this data when arranging future studies. Second, the results of this pilot study may not be generalizable as the sample size (respondents) makes up 25% of the total junior doctor population in just one healthcare institution. However, this was a pilot study. Third, the invited population of doctors are employees within the same healthcare establishment as the organiser of the study. Therefore, any non-responder or responder bias based on this cannot be ruled out. A sample size including junior doctors from different healthcare institutions would limit this bias.

This study has demonstrated the importance of evaluation of teaching material by junior doctors while developing a beginner’s guide to writing a clinical case report. Once the above action points and limitations have been taken into account and improvements made, further repeat evaluations by junior doctors will need to be undertaken while developing a robust beginner’s guide to writing a clinical case report.

Acknowledgments

The author would like to thank all the junior doctors who participated in this evaluation study.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained by all participants in this study. Not applicable issued approval Not applicable. This study did not require ethical approval on the account of it being registered with our Quality, Governance and Compliance Department as a Quality of Education Improvement Project. Participants were assured of strict anonymity and confidentiality during this study.

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.