Medical Case Report Template: Format and CARE Checklist

Start with the intended journal's instructions, then use CARE to check whether the clinical account is complete. A report usually needs the presentation, clinical course, diagnostic reasoning, interventions, follow-up, and a discussion of what can be learned. The outline below is a drafting aid, not an official CARE form or a universal journal template.

This page is for a manuscript describing an actual episode. For a short handover, referral, or clinical summary, use the separate clinical case summary guide. For a question to colleagues, use the peer-discussion guide. A scholarly report needs publication-specific work beyond either document.

State the learning point in one sentence. A report can examine a diagnostic challenge, an unexpected observation, or a care process; rarity alone does not establish its value. Identify the intended reader and check whether the journal accepts that article type before adapting your draft.

Record the journal's required template, section order, abstract structure, length limits, figure specifications, reference style, consent documents, disclosures, and submission charges or membership requirements. These can change. BMJ Case Reports, for example, says it requires its Word templates and explicit patient or guardian consent before review; those are that journal's requirements, not rules for every publisher.

Every bracket below is a format placeholder, not patient information or an example finding. Replace it only with verified information you are authorized to report. These prompts paraphrase CARE's reporting areas; use the official checklist and any applicable specialty guidance for the final check.

• Title: [main phenomenon] — a case report.
• Keywords: [specific terms required by the journal].
• Abstract: [relevance, presentation, assessment, intervention, outcome, and bounded lesson].
• Introduction: [why the observation matters, with relevant literature].
• Patient information: [necessary de-identified context and presenting concerns].
• Clinical findings: [relevant history and examination].
• Timeline: [ordered events, assessments, interventions, and follow-up].
• Diagnostic assessment: [methods, results, alternatives, challenges, and basis for the conclusion].
• Interventions: [what was administered, relevant details, and changes with reasons].
• Follow-up and outcomes: [observed course, assessment method, adherence, harms, and duration].
• Discussion: [literature context, interpretation, strengths, limitations, and main lesson].
• Patient perspective: [the patient's own contribution, if available and appropriate].
• Publication consent: [the accurate statement and documentation required by the journal].

Use this empty structure to organize an abstract: “Background: [the clinical issue and reason for reporting]. Case: [the verified presentation, key assessment, intervention if relevant, and observed follow-up]. Conclusion: [one supported lesson and its boundary].” These are instructions for fields, not a completed patient report. Change the headings to the journal's required format.

Do not invent a resolved diagnosis, laboratory value, favorable outcome, or quotation to finish a section. If information is unavailable, explain that transparently in the manuscript and ask the journal how to handle it. Write the abstract after the main account so it matches what the report actually supports.

CARE's author guidance suggests building the timeline before writing the narrative. Collect the relevant records in an approved workspace, distinguish the time of an event from the time it was documented, and reconcile conflicting accounts with the responsible team. Preserve meaningful intervals when reducing identifying detail.

Show what was known at each decision point. An ordered test is not a completed result; an absent note is not a negative finding. Identify which observations came from the patient, an examination, a report, or later recollection. Keep a private verification record rather than copying an identifiable chart into a public writing tool.

Describe how the proposed diagnosis was supported and what uncertainty remained. Explain important alternatives and findings that did not fit. For an intervention, distinguish its intended purpose from the outcome observed, including co-interventions, adverse effects, interrupted treatment, and incomplete follow-up where relevant.

One selected account cannot establish prevalence, comparative effectiveness, or that an intervention caused improvement. “Improved after” and “improved because of” are different claims. Compare the observation with appropriate literature, describe alternative explanations, and keep the conclusion proportional to the evidence rather than converting a case into a treatment recommendation.

Consent to treatment is not consent to publish. COPE's case-report guidance addresses permission for publication and the possibility of recognition. Explain the intended material and audience using the journal's process. Do not promise complete anonymity or assume that removing a name settles permission.

ICMJE says an identifiable patient should see the manuscript and give written informed consent for publication; potential Internet availability should be explained. Follow the journal's and institution's rules for documenting and securely retaining consent. Do not attach signed forms containing identifiers to the public article.

If the patient is a child, cannot provide consent, has died, or cannot be contacted, obtain advice from the journal and responsible institutional team. Proxy authority and exceptions depend on the circumstances and applicable rules; this template cannot decide them.

Review narrative details, pedigrees, images, captions, filenames, and metadata. Names are not the only identifying clues: a rare event combined with dates, occupation, location, or family details may identify someone. Remove nonessential detail and use an appropriate privacy review before release.

ICMJE warns that masking a patient's eyes is inadequate and that de-identification must not distort scientific meaning. Do not alter a result, anatomy, treatment, or event sequence to disguise identity. Consent and privacy review are complementary; neither a checklist nor a blur tool establishes that disclosure is authorized.

Check institutional requirements for access to records, publication approval, and any ethics determination. A case-report label does not automatically establish exemption from review. Describe the actual approval, waiver, or determination only when it has been obtained and is applicable.

Agree authorship and contributions early. ICMJE's criteria combine substantive contribution, drafting or critical review, final approval, and accountability. General supervision or proofreading alone does not meet all those criteria. Check the journal's policy and acknowledge other help appropriately.

If AI assists drafting or analysis, follow the journal's disclosure policy. ICMJE recommends explaining its use at submission and in the appropriate manuscript section; AI cannot be an author. Human authors remain responsible for accuracy, citations, originality, and the final text. Do not upload confidential patient material to an unapproved service or accept generated references without verification.

Read the manuscript once for clinical accuracy, once for the learning claim, and once for privacy and submission requirements. These checks serve different purposes. Keep a dated record of the version approved by the authors.

• Every clinical statement can be traced to the source record or a cited reference.
• The abstract, narrative, figures, and timeline agree; estimates and missing information remain visible.
• Consent, privacy, institutional requirements, and permissions for reused material are resolved.
• Authorship, funding, interests, and AI assistance are reported accurately.
• The journal's template and applicable reporting checklist are complete, with page references when requested.

EQUATOR distinguishes reporting completeness from study design and quality appraisal. A complete report can still contain a mistaken interpretation. This SameCase outline has not been validated for reporting quality, clinical outcomes, or publication acceptance. It cannot certify CARE compliance, provide legal permission, or guarantee peer review, indexing, or citations.

The linked CARE, ICMJE, and COPE materials describe reporting and editorial guidance; EQUATOR organizes related resources. They are not independent trials of this template. COPE's cited consent guidance dates from 2016, so check the destination journal's current requirements. No named clinician, journal editor, or publication-ethics reviewer has reviewed this article.