How to write your case report

After creating a new case, you’ll be taken to the case report writing view. From here, you can start writing the text of your case report. If you would like to write your report following a template based on the CARE guidelines, you can click the “More” button on the bottom right of the editing toolbar and then select “Add template.”

To insert a timeline, click the “More” button and then select “Timeline”. The timeline will be automatically inserted when using the template, but if you wish to add a timeline without using the template, you can insert one this way.

Each timeline entry has a date and a visit summary. Change the date by typing in a new date (formatted in MM/DD/YYYY) or by clicking the calendar icon and selecting a date that way, then clicking “Update date”. Timeline dates in your case report preview, downloadable PDF, and public report will be formatted as YYYY/MM/DD.

To create a new timeline entry, click the “+Add” button that appears in the upper right part of the timeline entry you currently have selected. To delete a timeline entry, click the “Delete” button.

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.