This checklist was developed by CARE to correspond with key components of a case report and capture useful clinical information (including 'meaningful use' information mandated by some insurance plans).
The narrative: A case report tells a story in a narrative format that includes the presenting concerns, clinical findings, diagnoses, interventions, outcomes (including adverse events), and follow-up. The narrative should include a discussion of the rationale for any conclusions and any take-away messages.
| Topic | Item | Checklist Item Description |
| Title | 1 | The words "case report: should be in the title, along with area of focus |
| Keywords | 2 | Four to seven keywords - include "case report" as one of the keywords |
| Abstract | 3a | Background: What does this case report add to the medical literature? |
| 3b | Case summary: chief complaint, diagnoses, interventions, and outcomes | |
| 3c | Conclusion: What is the main "take-away" lesson from this case? | |
| Introduction | 4 | The current standard of care and contributions of this case - with references (1-2 paragraphs) |
| Timeline | 5 | Information from this case report organized into a timelines (table or figure) |
| Patient Information | 6a | De-identified demographic and other patient or client specific information |
| 6b | Chief complaint - what prompted the visit? | |
| 6c | Relevant history including past interventions and outcomes | |
| Physical Exam | 7 | Relevant physical examination findings |
| Diagnostic Assessment | 8a | Evaluations such as surveys, laboratory testing, imaging, etc. |
| 8b | Diagnostic reasoning including other diagnoses considered and challenges | |
| 8c | Consider tables or figures linking assessment, diagnoses, and interventions | |
| 8d | Prognostic characteristics where applicable | |
| Interventions | 9a | Types such as lifestyle recommendations, treatments, medications, surgery |
| 9b | Intervention administration such as dosage, frequency, and duration | |
| 9c | Note changes in intervention with explanation | |
| 9d | Other concurrent interventions | |
| Follow-up and Outcomes | 10a | Clinician assessment (and patient or client assessed outcomes when appropriate) |
| 10b | Important follow-up diagnostic evaluations | |
| 10c | Assessment of intervention adherence and tolerability, including adverse events | |
| Discussion | 11a | Strengths and limitations in your approach to the case |
| 11b | Specify how this case report informs practice or Clinical Practice Guidelines (CPG) | |
| 11c | How does this case report suggest a testable hypothesis? | |
| 11d | Conclusions and rationale | |
| Patient Perspective | 12 | When appropriate, include the assessment of the patient or client on this episode of care |
| Informed Consent | 13 | Informed consent from the person who is the subject of this case report, required by most journals |
| Additional Information | 14 | Acknowledgement section; Competing Interests; IRB approval when required |
Gagnier JJ, Riley D, Altman DG, Moher D, Sox H, Kienle GS, for the CARE group: The CARE guidelines: Consensus-based clinical case reporting guideline development. Dtsch Arztebl Int 2013; 110(37): 603-8.
