This set of guidelines provides both instructions and a template for the writing of case reports for publication. You might want to skip forward and take a quick look at the template now, as we will be using it as the basis for your own case study later on. While the guidelines and template contain much detail, your finished case study should be only 500 to 1,500 words in length. Therefore, you will need to write efficiently and avoid unnecessarily flowery language.
These guidelines for the writing of case studies are designed to be consistent with the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” referenced elsewhere in the JCCA instructions to authors.
After this brief introduction, the guidelines below will follow the headings of our template. Hence, it is possible to work section by section through the template to quickly produce a first draft of your study. To begin with, however, you must have a clear sense of the value of the study which you wish to describe. Therefore, before beginning to write the study itself, you should gather all of the materials relevant to the case – clinical notes, lab reports, x-rays etc. – and form a clear picture of the story that you wish to share with your profession. At the most superficial level, you may want to ask yourself “What is interesting about this case?” Keep your answer in mind as your write, because sometimes we become lost in our writing and forget the message that we want to convey.
Another important general rule for writing case studies is to stick to the facts. A case study should be a fairly modest description of what actually happened. Speculation about underlying mechanisms of the disease process or treatment should be restrained. Field practitioners and students are seldom well-prepared to discuss physiology or pathology. This is best left to experts in those fields. The thing of greatest value that you can provide to your colleagues is an honest record of clinical events.
Finally, remember that a case study is primarily a chronicle of a patient’s progress, not a story about chiropractic. Editorial or promotional remarks do not belong in a case study, no matter how great our enthusiasm. It is best to simply tell the story and let the outcome speak for itself. With these points in mind, let’s begin the process of writing the case study:
Title: The title page will contain the full title of the article. Remember that many people may find our article by searching on the internet. They may have to decide, just by looking at the title, whether or not they want to access the full article. A title which is vague or non-specific may not attract their attention. Thus, our title should contain the phrase “case study,” “case report” or “case series” as is appropriate to the contents. The two most common formats of titles are nominal and compound. A nominal title is a single phrase, for example “A case study of hypertension which responded to spinal manipulation.” A compound title consists of two phrases in succession, for example “Response of hypertension to spinal manipulation: a case study.” Keep in mind that titles of articles in leading journals average between 8 and 9 words in length.
Other contents for the title page should be as in the general JCCA instructions to authors. Remember that for a case study, we would not expect to have more than one or two authors. In order to be listed as an author, a person must have an intellectual stake in the writing – at the very least they must be able to explain and even defend the article. Someone who has only provided technical assistance, as valuable as that may be, may be acknowledged at the end of the article, but would not be listed as an author. Contact information – either home or institutional – should be provided for each author along with the authors’ academic qualifications. If there is more than one author, one author must be identified as the corresponding author – the person whom people should contact if they have questions or comments about the study.
Key words: Provide key words under which the article will be listed. These are the words which would be used when searching for the article using a search engine such as Medline. When practical, we should choose key words from a standard list of keywords, such as MeSH (Medical subject headings). A copy of MeSH is available in most libraries. If we can’t access a copy and we want to make sure that our keywords are included in the MeSH library, we can visit this address: http://www.ncbi.nlm.nih.gov:80/entrez/meshbrowser.cgi
Abstract: Abstracts generally follow one of two styles, narrative or structured.
A narrative abstract consists of a short version of the whole paper. There are no headings within the narrative abstract. The author simply tries to summarize the paper into a story which flows logically.
A structured abstract uses subheadings. Structured abstracts are becoming more popular for basic scientific and clinical studies, since they standardize the abstract and ensure that certain information is included. This is very useful for readers who search for articles on the internet. Often the abstract is displayed by a search engine, and on the basis of the abstract the reader will decide whether or not to download the full article (which may require payment of a fee). With a structured abstract, the reader is more likely to be given the information which they need to decide whether to go on to the full article, and so this style is encouraged. The JCCA recommends the use of structured abstracts for case studies.
Introduction: This consists of one or two sentences to describe the context of the case and summarize the entire article.
Case presentation: Several sentences describe the history and results of any examinations performed. The working diagnosis and management of the case are described.
Management and Outcome: Simply describe the course of the patient’s complaint. Where possible, make reference to any outcome measures which you used to objectively demonstrate how the patient’s condition evolved through the course of management.
Discussion: Synthesize the foregoing subsections and explain both correlations and apparent inconsistencies. If appropriate to the case, within one or two sentences describe the lessons to be learned.
Introduction: At the beginning of these guidelines we suggested that we need to have a clear idea of what is particularly interesting about the case we want to describe. The introduction is where we convey this to the reader. It is useful to begin by placing the study in a historical or social context. If similar cases have been reported previously, we describe them briefly. If there is something especially challenging about the diagnosis or management of the condition that we are describing, now is our chance to bring that out. Each time we refer to a previous study, we cite the reference (usually at the end of the sentence). Our introduction doesn’t need to be more than a few paragraphs long, and our objective is to have the reader understand clearly, but in a general sense, why it is useful for them to be reading about this case.
Case presentation: This is the part of the paper in which we introduce the raw data. First, we describe the complaint that brought the patient to us. It is often useful to use the patient’s own words. Next, we introduce the important information that we obtained from our history-taking. We don’t need to include every detail – just the information that helped us to settle on our diagnosis. Also, we should try to present patient information in a narrative form – full sentences which efficiently summarize the results of our questioning. In our own practice, the history usually leads to a differential diagnosis – a short list of the most likely diseases or disorders underlying the patient’s symptoms. We may or may not choose to include this list at the end of this section of the case presentation.
The next step is to describe the results of our clinical examination. Again, we should write in an efficient narrative style, restricting ourselves to the relevant information. It is not necessary to include every detail in our clinical notes.
If we are using a named orthopedic or neurological test, it is best to both name and describe the test (since some people may know the test by a different name). Also, we should describe the actual results, since not all readers will have the same understanding of what constitutes a “positive” or “negative” result.
X-rays or other images are only helpful if they are clear enough to be easily reproduced and if they are accompanied by a legend. Be sure that any information that might identify a patient is removed before the image is submitted.
At this point, or at the beginning of the next section, we will want to present our working diagnosis or clinical impression of the patient.
Management and Outcome: In this section, we should clearly describe the plan for care, as well as the care which was actually provided, and the outcome.
It is useful for the reader to know how long the patient was under care and how many times they were treated. Additionally, we should be as specific as possible in describing the treatment that we used. It does not help the reader to simply say that the patient received “chiropractic care.” Exactly what treatment did we use? If we used spinal manipulation, it is best to name the technique, if a common name exists, and also to describe the manipulation. Remember that our case study may be read by people who are not familiar with spinal manipulation, and, even within chiropractic circles, nomenclature for technique is not well standardized.
We may want to include the patient’s own reports of improvement or worsening. However, whenever possible we should try to use a well-validated method of measuring their improvement. For case studies, it may be possible to use data from visual analogue scales (VAS) for pain, or a journal of medication usage.
It is useful to include in this section an indication of how and why treatment finished. Did we decide to terminate care, and if so, why? Did the patient withdraw from care or did we refer them to another practitioner?
Discussion: In this section we may want to identify any questions that the case raises. It is not our duty to provide a complete physiological explanation for everything that we observed. This is usually impossible. Nor should we feel obligated to list or generate all of the possible hypotheses that might explain the course of the patient’s condition. If there is a well established item of physiology or pathology which illuminates the case, we certainly include it, but remember that we are writing what is primarily a clinical chronicle, not a basic scientific paper. Finally, we summarize the lessons learned from this case.
Acknowledgments: If someone provided assistance with the preparation of the case study, we thank them briefly. It is neither necessary nor conventional to thank the patient (although we appreciate what they have taught us). It would generally be regarded as excessive and inappropriate to thank others, such as teachers or colleagues who did not directly participate in preparation of the paper.
References: References should be listed as described elsewhere in the instructions to authors. Only use references that you have read and understood, and actually used to support the case study. Do not use more than approximately 15 references without some clear justification. Try to avoid using textbooks as references, since it is assumed that most readers would already have this information. Also, do not refer to personal communication, since readers have no way of checking this information.
A popular search engine for English-language references is Medline: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi
Legends: If we used any tables, figures or photographs, they should be accompanied by a succinct explanation. A good rule for graphs is that they should contain sufficient information to be generally decipherable without reference to a legend.
Tables, figures and photographs should be included at the end of the manuscript.
Permissions: If any tables, figures or photographs, or substantial quotations, have been borrowed from other publications, we must include a letter of permission from the publisher. Also, if we use any photographs which might identify a patient, we will need their written permission.
In addition, patient consent to publish the case report is also required.
This section provides some advice on the process of writing up your report.
Plan the report
Before you begin to write the report, it is essential to have a plan of its structure. You can begin to plan the report while you are investigating the case.
Fist, prepare an outline (in list or mind-map format) of the main headings and subheadings you will have in the report. Then add notes and ideas to the outline which remind you of what you want to achieve in each section and subsection. Use the outline to help you consider what information to include, where it should go and in what sequence. Be prepared to change your outline as your ideas develop. Finally, the outline headings and subheadings can be converted into the contents page of your report.
Schedule your writing time
Prepare a schedule for writing and editing the sections of the report. Allow some extra time just in case you find some sections difficult to write. Begin by writing the sections you feel most confident about. Preliminary sections (executive summary, introduction) and supplementary sections (conclusions, reference list and appendices) are usually prepared last. Some writers like to begin with their conclusions (where the writer's thoughts are at that moment) or the methodology (it's easier to write about your own work).
Analyse your audience
In writing a case study report in your course, the report is often intended for an imaginary person so you need to make sure that your language and style suites that person. For example, a report for senior management will be different in content and style and language to a technical report. A report to a community group would also be different again in content, style and language. Audience definition helps you decide what to include in the report based on what readers need to know to perform their jobs better or what the readers need to know to increase their knowledge about your subject. These notes on audience analysis are adapted from Huckin and Olsen (p1991)
*After: Huckin & Olsen ,1991.1.
- Who will read the report? Think about all the uses of the report and where and when it would be read. Reports written within an organisation may be read by different people and different departments; for example, technical and design specialists, supervisors, senior managers, lawyers, marketing and finance specialists.
- What are the readers' needs and goals? Each department or unit in an organisation has its own needs and goals. Understanding the different perspectives can help you decide how to communicate persuasively to these groups. For example while design engineers may prefer to develop new or alternative design to show progress in their field, the marketing specialist may prefer that the organisation imitate a known successful design to save time.
- How do I make communication clear for managers? Communication must be accessible and useful to busy managers as they will primarily seek important generalisations. This has implications for the report's structure, the amount of orientation or background information provided and the level of technical language used. An executive summary, introductions to new sections and concluding summaries for major sections should be included in the report.
- What might be the readers' preferences or objections to the report? You may need to address the significance and benefits/limitations of your recommendations from a number of readers' perspectives in the report. You may also need to consider compromises as a way to acknowledge potential conflicts or criticisms of your recommendations or solutions.
Prepare a draft report
Writers rarely produce a perfect piece of text in their first attempt so a number of drafts are usually produced. Careful planning and editing will ensure a consistent professional standard in the report. You will need to do the following:
- Revise the task often
Do this by keeping both the reader's needs and the report's objectives in mind as you gather information, take notes and write sections of the report.
Do this by taking clear notes, which include the information gathered and your thoughts about the usefulness and the implications of this information. Review your notes to decide what is essential information to include in the report.
- Create a logical structure
Use your contents page outline to decide where information will go. Within each section, plan the subheadings and then decide on the sequence of information within these.
Check that your writing flows and that your ideas are supported and plausible. If you are not sure what to look for, here are links to advice and activities on report organisation, cohesion and evidence.
Ensure that all your figures and tables communicate a clear message. Show a colleague your visuals to check how they will be interpreted or 'read'.
For first drafts, a word processor's spell checker and grammar checker can be useful however, do not rely solely on these tools in your final edit as they are not perfect. Errors will be overlooked or even created by these programs! The best ways to edit are to read a printed copy and where possible get a colleague to read and give feedback.
Here is a report checklist that you can print out: CHECKLIST