How to write your case report

After creating a new case, you’ll be taken to the case report editor view. From here, you can start writing the text of your case report.

On the right-hand side is a document outline which lists the sections of a case report in the order in which they appear in the final published document. However, the best order in which to write these sections is somewhat different. We group each of these sections into three categories, and they should ideally be completed in order:

  1. What Happened

    –Timeline
    –Diagnostics
    –Narrative
    –Patient Perspective

  2. Why It Might Have Happened

    –Introduction
    –Discussion
    –Conclusion

  3. Supporting Sections
    –Abstract
    –Keywords
    –Acknowledgements
    –References

You can navigate to each of these categories using the left side panel, and then you can select a section from the list. Clicking the “Requirements” button in the category pane will reveal a list of tasks to complete for each category.

To add a new section to your case report beyond those that are included by default, click the “Sections” button in the upper right. This will open a pane on the right side of the screen. From here, you can click any of the “+ Add section” buttons (whether at the beginning, in between existing sections, or at the end). Use the first dropdown menu to choose whether you wish to create a text section, a diagnostics section, or a timeline section. Select an option from the second dropdown menu to designate which of the three main categories this section will reside in (What, Why, or Supporting). Lastly, use the text field to give the section a title.

You can also use this sidebar to rearrange the sections of your case report. Simply click the handle on the left side of the section and drag it into the order you wish. To delete a section, click the three dots on the right side, then select “Delete.”

Below you will find explanations of the information to include in the text field sections of your case report.

Title

The title for your case report should be short and provide a description of the focus of your case report followed by the words “a case report.” The title you choose may be edited at any time. Make sure you de-identify all patient information and have informed patient consent on file.

Keywords

Enter five keywords for your case report to aid readers conducting a digital search. The keyword “case report” will be added automatically.

Abstract

The abstract (best written last), is short, and may be structured or unstructured. The abstract is written without references and should be in the English language. A structured abstract should include three sections: (1) Background, (2) Case Information, and (3) Conclusion.

Introduction

The introduction (1–2 paragraphs) provides a brief overview of the case and may include an important scientific references. It should also include a 1–2 sentence overview of the patient followed by your key “take-away” message(s) for the reader. Please end the introduction with “This case report follows the CARE Guidelines” (Citation: Riley DS, Barber MS, Kienle GS, et al. CARE Explanation and Elaborations: Reporting Guidelines for Case Reports. J Clin Epi 2017 Sep;89:218-235. doi: 10.1016/jclinepi.2017.04.026).

Narrative

The narrative (3–5 paragraphs) provides a description of WHAT happened and should be consistent with the timeline automatically created by CARE-writer from the visit summaries. It usually includes demographic information, history, clinical findings, diagnostic assessments, therapeutic interventions, and final outcome. Make sure you de-identify all patient information and report any adverse events.

Patient Perspective

The patient’s perspective is a brief description of the care received from the patient's perspective. It may describe their motivations for seeking care or report changes that occurred. (You may wish to obtain informed consent at the same you ask the patient for their perspective.)

Discussion

The discussion is a description of WHY the results reported in this case might have happened. The discussion section should include relevant scientific references. A discussion of potential limitations is also important. Case reports may discuss outcomes from a patient receiving more than one therapeutic intervention, often making it challenging to determine which intervention caused which outcome.

Conclusion

The conclusion is usually a one-paragraph summary (without references) stating the primary “take-away” message(s) for the reader.

Acknowledgements

The acknowledgements section should mention the credentials and affiliations for each author and any potential conflicts of interest including funding.