How to Write a Clinical Report

When writing a clinical report, you must first determine whether your case report is worthy of publication. Scientific and medical journals seek specific types of cases including negative responses to therapies, atypical observations, a combination of factors that created confusion, a situation that throws a current theory into question, a new theory or, in some situations, a case that had a dramatic impact on the clinician. Once you have determined that the case is publishable, selected an appropriate journal for the submission and get the patient's written authorization to publish the study.

Things You'll Need

• Patient consent
• Extensive notes
• Journal requirements

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Instructions

• 1

  Learn what the editors want and need for their specific journal.

  Check the journal or its website to find the publication's instructions for authors. In general, journal articles have a similar structure; however, specific journals may have different requirements. Before writing, read articles from the selected journal to become familiar with composition and structure as well as the amount of detail the editors want or expect.

• 2

  Carefully outline your clinical report.

  Outline your clinical report, including an introduction, case study, discussion and, if the journal requires them, a review of the literature and a conclusion. Some journals require only the introduction, case study and discussion, in which case the latter can include the literature review and conclusion.

• 3

  Your introduction should detail the larger problem your case reveals.

  Write the introduction by outlining the bigger problem the case addresses and include citations from medical literature. You are not detailing the entire case, simply stating the overarching situation or occurrence. Often the introduction ends with a specific description; for example, "This case report describes clinical characteristics of a 60-year-old woman with multiple sclerosis and acute depression."

• 4

  Detail your case including all pertinent factors.

  Present the case in detail. Open by describing the individual and her situation from the onset of the disease or condition to the present. Detail the physical exam, pertinent test results and detailed information on the prescribed treatment. Finally, distinguish the expected outcome from the actual result where the atypical or abnormal occurrence took place.

• 5

  Include a review of the key literature pertaining to your clinical report.

  Include the literature review, focusing on research findings that point to what the outcome of the treatment should have been and how the actual event or occurrence departed from the expected outcome detailed in the literature. Generally, if you are citing research throughout the work, it is best to present general research findings in the introduction and the more specific findings in the discussion.

• 6

  The discussion is the most important element in your clinical report.

  Write the discussion, being mindful that it is the most important part of the study. Detail why your case is singular or exceptional and outline specific circumstances or instances that make it puzzling or atypical. Describe the discovery of the atypical outcome and contrast it to the expected outcome. If this case flies in the face of an existing theory, you might propose a new one.

• 7

  Your conclusion should include a "takeaway message."

  Wrap up the clinical report with a conclusion that has a "takeaway message" and possibly recommendations for other practitioners or clinicians.