CENTRAL LUZON DOCTORS’ HOSPITALEDUCATIONAL INSTITUTION
San Pablo, Tarlac City
CASE STUDY FORMAT
I.IntroductionII.ObjectivesNurse centeredIII.Nursing ProcessA.Data Basea.Nursing health history A1.Demographic data2.Chief complaint3.History of present illness4.Past medical history5.Family history6.Social and personal history7.Review of systemb.Nursing health history B1.General Description Of Client2.Health Perception-Health Management Pattern3.Nutritional-Metabolic Pattern4.Elimination Pattern5.Activity-Exercise Pattern6.Sleep-Rest Pattern7.Cognitive-Perceptual Pattern8.Self-Perception – Self-Concept Pattern9.Role-Relationship Pattern10.Sexuality-Reproductive Pattern11.Coping-Stress Tolerance Pattern12.Value-Belief Patternc.Physical examinationd.Laboratory Findingse.Review of anatomy and physiologyf.Pathophysiology (highlight patient manifestation)B.NCPC.Drug StudyD.Medical and Nursing ManagementE.METHODIV.Evaluation
Narrative evaluation of the objectives
Patient condition upon dischargeV.Recommendation
Case Study Report Documents
Definition of a case study report
A case study report is an article that describes a particular patient's diagnosis and treatment plan. Most of the cases chosen for published medical case studies are of unusual diagnoses, or include complications in treatment. A case study report is written in a specific format and can be submitted to peer-reviewed journals. To write a case study report, the following steps need to be undertaken:
1. Generate a Barwon Health reference number
2. Select a case
- Case reports are written about patients who have rare or unusual illnesses, or where a treatment plan has an unexpected positive or negative outcome - get support from your line manager and advise the Research Ethics, Governance & Integrity (REGI) Unit.
3. Research the case/literature review
4. Provide patient information and seek consent
- The patient who is the focus of the medical case study report must provide written consent (many journals have their own consent forms that must be completed and signed by the patient before the report is submitted) - provide the patient with the Participant Explanatory Statement and seek the patient's consent by providing the patient with the Participant Consent Form
- The consent is to use both patients' data for the purposes of publication, and to access the medical records, including other organisations if required
- Gather the patient's demographic information (age, medical history, medication use, current and past diagnoses, etc.), and provide detailed information about the patient so the audience will be well informed about the case
- Collect relevant copies of the patient's labs, x-rays, or any clinical photographs.
5. Write the medical case study report
- Follow the standard format for the report, as outlined in the Case Study Report Template, sign the Researcher(s) Declaration, and submit to the REGI Unit.
6. Submit your medical case study report to the appropriate professional journal
7. Keep your source records
- Keep a clear record of the progress in writing up the case, in the event of queries or audits - records are usually stored at least one year after publication, or longer in some cases.