Process of Effective Medical Case Report Writing
Individual cases of the patients are the essence of medical science as they provide very first presentation of the discoveries such as new conditions, diseases, pathologies, diagnostic procedures, treatments etc. Although case reports are not considered the primary data source and given weightage in the medical literature, yet they provide information on new management options and meaningful knowledge to the medical fraternity. The high-quality, professionally written case reports allows global convergence of conventional and new healthcare systems thus, facilitating the design and conduct of clinical trials and ultimately improving the patient care. Hence, effective writing of case reports is an essential segment of the information sharing across indications and therapies/regimens. Several guidelines are available on the appropriate reporting of patient cases and their systematic documentation and publications including CARE (CAse REport) guidelines.
Effective writing of a case report include gathering all the relevant information into one place, including history and physical exam notes, lab reports, imaging, follow-up details and current status of the patient. If possible, discussion with patient itself may provide supplement to the clinical information for the case report. While the writing part is concerned, breaking the case report in different sections would be a better idea. The below figure provides a detailed description of the different sections of the case report and how to write information in these sections.