By the WoundSource Editors
Writing up a case report is an important professional activity in not only wound care, but in any other field as well. A case report records the details of the presentation of signs and symptoms, assessment, diagnosis, treatment and outcomes of a patient case or series of cases. Case reports typically describe an unusual presentation or complication relating to the patient's condition, or a new clinical approach to a common problem. The publication of a case report in a peer-reviewed journal, if that is your intent, is a great addition to your CV, especially if you are new to the profession.
Following are general steps to take in creating a patient case report.
1. Talk to Colleagues:
If you encounter a striking or unique patient case in your clinical practice that seems worthy of a case report, talk to your colleagues and senior clinicians to determine if the patient case is of interest for further research and documentation in the form of a case report. Also, determine what protocol you must follow within your facility to gain permission and access to take on the composition of the case report.
2. Conduct Research:
Once you have determined the viability of a patient case for a case report, conduct research to ensure this case will present new and/or unique findings to the wound care community. Use online medical databases to research peer-reviewed journal articles to review similar cases and/or the condition(s) presenting in your patient. Conducting this early stage of research will not only validate your case by allowing you to see what's already been published on the subject, it also help you compile your research for inclusion in the case report.
3. Seek Permission:
Gain the permission of the patient(s), or in the case of a deceased patient, the next-of-kin. You may also need to seek permission from the patient's primary case manager depending on your position and facility protocol. Many journals require patient consent in order for a case study to be considered for publication, and may have their own permission form requirements. Receiving clearance from the patient is essential to the presentation of your patient's case, especially if it is your intention to submit the case report for publication.
4. Compile the Patient Background and History:
Create the presentation of the patient case and wound care treatment. Include the clinical background of the case. It is in this section that you will describe the case and start with the basics:
- Who is the patient?
- What type of wound is it?
- Describe the medical history of the patient
Example: TJ is a 55 year old woman presenting to the wound clinic with a venous ulcer to her left lateral lower leg. TJ has a history of anemia, medication controlled hypertension, and varicose veins that initially presented six years ago.
5. Document Wound Assessment:
Once you have set the stage, follow up with the wound assessment. Describe the location, etiology, wound history, size, and appearance of tissue, exudate and periwound skin. Remember to incorporate any information that is relevant to potential barriers to healing such as co-factors, patient compliance issues or other complications that arise during treatment.
Example: Ulceration to the left lateral lower leg with a history of being present for 45 days. The wound is partial-thickness, 3x4cm with a depth of 2mm. Explain tissue type, amount of tissue by type, exudate characteristics and amount.
6. Describe Treatment Protocol:
The next section should address and explain the treatment protocol that was implemented. Describe your wound management approach here. List what treatment intervention and/or product(s) were used, how much, frequency of dressing change and any other pertinent information.
Example: Using an alginate dressing 4x4 to the wound bed followed by applying a skin barrier ointment to the periwound area, cover wound with a foam dressing and secure with a four-layer compression system. Change the wound covering and compression every four days.
7. Document Results:
Describe and detail what wound changes you observed and at what time intervals during the treatment process. Discuss how many days transpired until closure was observed.
Example: Protocol initiated and on day four of the treatment the wound had decreased in size to 2x1cm, depth 1mm. Periwound erythema and maceration resolved. The protocol was continued for 20 days. On day 24 the wound had closed, the periwound skin was intact and without evidence of maceration. Compression was continued on a weekly change schedule.
8. Include Photo Documentation and Clinical Data:
Include any photo documentation that you have taken. It is a good idea to show a comparative "before" photo taken at the beginning of the wound care intervention, allowing you to demonstrate the wound healing in progress, and the wound closure on your patient's last visit.
Provide graphic data in the form of charts, graphs and other visual depictions to support your case findings and/or treatment outcomes.
9. Product Name Citation:
When using the product's name, use the service or trademark that you can find on the package, insert or user information. List any of the product's trademarks at the end of your discussion.
Include any literature citation that you reviewed in developing or evaluating your protocol. It is permissible to list Instructions for Use (IFU) information.
Now you are on your way to sharing your wound care experiences with your colleagues through professional wound care case reports.
Editor's Note: This article was originally published on November 11th, 2010 and has been updated and expanded for comprehension.