If you’re a new medical writer, you probably find yourself looking for templates and document guidelines to help you organize your work. Whether you’re a new graduate or an experienced scientist pivoting into a new career, you’ll need to spend time learning the purpose of each type of medical document in your niche and structuring it properly. Below, we offer an explanation of and guidance for writing clinical case reports.
What Is a Clinical Case Report?
Clinical case reports are instructional documents written by clinicians, often with assistance from medical writers who are experienced in writing scientific publications. Clinical case reports, which are published in medical journals, present a detailed description of an interesting or unusual patient case. These documents are a way to spread new observations and knowledge throughout the medical community, whether to experienced medical practitioners, students, or other health care professionals.
Throughout their years of work, medical practitioners come across a variety of puzzling or complex illnesses, side effects, and patient cases. Whenever an unusual or noteworthy case occurs, there’s an opportunity for the case to help teach other medical professionals about the physician’s observations, diagnosis, and treatment plan. A written report of the patient case and resulting treatment and outcome is called a clinical case report.
How Should I Structure a Clinical Case Report?
Fortunately, writing a clinical case report is not a guessing game. The CARE guidelines (for CAse REports) were last published in the Journal of Clinical Epidemiology in 2017. These guidelines, which were developed by an international group of experts, were first laid out in 2013. These guidelines were designed to support consistency, accuracy, and the potential for peer review and publication in medical journals.
The CARE guidelines are an invaluable resource for new and veteran medical writers. The CARE checklist for clinical case reports outlines 13 document sections to include in a clinical case report. Medical writers interested in crafting a clinical case report should download and print the entire checklist. It’s a helpful tool to keep handy at your desk.
Keep in mind that every medical journal has its own guidelines for what to include in a clinical case report and how to structure the document. Nevertheless, the focus should be the patient and what was unique about the case. The case presentation should be concise, with clear take‑away messages that clinicians can put into practice.
4 Keys for Successful Clinical Case Report Writing
The CARE guidelines will help you structure your clinical case report, but there is also an art to these documents. Below, we outline four keys for a successful approach to the research and writing processes.
1. Prepare to ask a lot of questions
As you assist authors, one of the most important ways to set yourself up for success is to ask plenty of questions, including:
- What key takeaway message will this clinical case report address for clinicians?
- What can you assume readers will already know?
- What new information will this case add to the existing literature?
It’s important to seek expert input so that you don’t miss or misrepresent critical information. Do you know the standard and abnormal values for related laboratory tests? Do you thoroughly understand the symptoms and treatment methods used in the case?
2. Think like a journalist
More than perhaps any other type of medical document, a clinical case report tells a story. Answer the basic questions covered in all news stories:
- Who?
- When?
- Where?
- Why?
- How?
Journalists also carefully consider which details are important to the story. Some descriptions and human‑interest details help make the case compelling. Other details might distract the reader or add a sheen of drama that feels inappropriate for a clinical case report.
3. Add visuals
Clinical case reports are learning tools. Adding photographs, X‑ray images, or other medical visuals will augment the document’s appeal and learning potential.
Remind authors to get consent before using anything from patient records. It’s also important to block out all identifying information.
4. Seek acknowledgement
Medical writers help clinicians to write clinical case reports. The clinicians are the authors of the final publication. An author is generally considered to be someone who made substantive intellectual contributions to a published paper, was involved in drafting or revising the manuscript, and gave final approval for the version that was published. Medical writers who provide technical help and writing assistance but don’t meet the criteria for authorship should be listed in an Acknowledgements section.
Once you’ve written your first clinical case report, ask a fellow medical writer to read it over for you. Peer reviews are critical for accuracy and transparency. The more mentors, experts, and colleagues who review your work, the stronger your final document and clinical case report writing skills will be.
