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• Volume 56, Issue 12
• Writing up your clinical trial report for a scientific journal: the REPORT trial guide for effective and transparent research reporting without spin
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• http://orcid.org/0000-0001-6884-1971 Thomas Bandholm 1 , 2 , 3 , 4 ,
• http://orcid.org/0000-0001-9102-4515 Kristian Thorborg 2 , 4 , 5 ,
• http://orcid.org/0000-0001-8102-3631 Clare L Ardern 6 , 7 , 8 ,
• Robin Christensen 9 , 10 ,
• http://orcid.org/0000-0003-1091-2962 Marius Henriksen 9
• 1 Department of Clinical Research , Copenhagen University Hospital, Amager and Hvidovre , Copenhagen , Denmark
• 2 Department of Occupational and Physical Therapy, Physical Medicine & Rehabilitation Research – Copenhagen (PMR-C) , Copenhagen University Hospital, Amager and Hvidovre , Copenhagen , Denmark
• 3 Department of Orthopaedic Surgery , Copenhagen University Hospital, Amager and Hvidovre , Copenhagen , Denmark
• 4 Department of Clinical Medicine , University of Copenhagen , Copenhagen , Denmark
• 5 Department of Orthopaedic Surgery, Sports Orthopedic Research Center – Copenhagen (SORC-C), Amager-Hvidovre Hospital, Faculty of Health Sciences , Copenhagen University , Copenhagen , Denmark
• 6 Musculoskeletal & Sports Injury Epidemiology Centre, Department of Health Promotion Science , Sophiahemmet University , Stockholm , Sweden
• 7 Sport and Exercise Medicine Research Centre , La Trobe University , Melbourne , Victoria , Australia
• 8 Department of Family Practice , University of British Columbia , Vancouver , British Columbia , Canada
• 9 The Parker Institute, Section for Biostatistics and Evidence-Based Research , Copenhagen University Hospital Bispebjerg Frederiksberg , Copenhagen , Denmark
• 10 Department of Clinical Research, Research Unit of Rheumatology , University of Southern Denmark, Odense University Hospital , Odense , Denmark
• Correspondence to Dr Thomas Bandholm, Dept of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre DK-2650, Denmark; thomas.quaade.bandholm{at}regionh.dk

The REPORT guide is a ‘How to’ guide to help you report your clinical research in an effective and transparent way. It is intended to supplement established first choice reporting tools, such as Consolidated Standards of Reporting Trials (CONSORT), by adding tacit knowledge (ie, learnt, informal or implicit knowledge) about reporting topics that we have struggled with as authors or see others struggle with as journal reviewers or editors. We focus on the randomised controlled trial, but the guide also applies to other study designs. Topics included in the REPORT guide cover reporting checklists, trial report structure, choice of title, writing style, trial registry and reporting consistency, spin or reporting bias, transparent data presentation (figures), open access considerations, data sharing and more. Preprint (open access): https://doi.org/10.31219/osf.io/qsxdz .

• sports medicine
• randomized controlled trial

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bjsports-2021-105058

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Introduction

You worked hard as the primary investigator of a clinical research project. You spent months preparing the project, 1 and perhaps years collecting and analysing data. You are now ready to report the work as a scientific paper (hereafter ‘trial report’), and submit it to a peer-reviewed, academic journal. You aim for quality and transparency because you want the end-user to be able to read-and-implement for clinical work or read-and-replicate for research. Your coauthors have different and contrasting input to your manuscript draft. How do you navigate this scenario?

Let us introduce the REPORT guide. It is intended to improve reporting of clinical research in general. 2 It is not intended to replace established reporting checklists such as Consolidated Standards of Reporting Trials (CONSORT) 3 —they are always your ‘first choice’ reporting guidance resources. Rather, we intend the REPORT guide as a ‘How to’ implementation guide and directory that holds tacit knowledge (ie, learnt, informal or implicit knowledge) and references to sources of information about effective and transparent trial reporting. We have included information on topics we have struggled with ourselves as authors and see authors struggle with when we review or edit submitted clinical trial research. We published the PREPARE trial guide in 2017 1 which aimed to assist in the preparation and planning of clinical trial research. The REPORT guide is a natural extension of PREPARE—focusing on reporting of clinical trial research. If you used the PREPARE trial guide 1 to plan your research, the REPORT guide will likely help you report it. The REPORT guide can also function as a stand-alone guide to help you report research no matter how it was prepared.

The REPORT guide provides information to help improve reporting quality and transparency. The focus is the randomised controlled trial (RCT) (hereafter ‘trial’), but the guide is useful for other study designs.

The CONSORT checklist and CONSORT-based web tool writing aid tool: an important first step

An important first reporting step is to locate a reporting checklist that matches your study design. A comprehensive list of reporting checklists can be found at the EQUATOR network’s website. 4 For a trial, the appropriate reporting checklist is the CONSORT checklist 3 for which there are several extensions that may be relevant. We encourage you to go to the ‘Toolkits’ section at the EQUATOR network’s website 5 where you can find information to help you select the appropriate reporting checklist. You may also find the CONSORT-based WEB tool (COBWEB) 6 useful in your writing and checklist adherence. As stated on the COBWEB(site): ‘COBWEB is an online manuscript writing aid tool intended to guide authors through the process of manuscript writing of RCTs in line with the Consolidated Standards of Reporting Trials (CONSORT) and its subsequent extensions’. We highly recommend you use this tool, as it will facilitate effective trial reporting. It will help you avoid many of the documented problems with CONSORT adherence, such as poor reporting of randomisation methods or description of sample size estimation. 7

For more information on reporting checklists: 1 4 6 8 9

Keep the trial protocol and registration next to you as you write the report

Journal reviewers and editors will be some of the first professional readers of your trial report when submitted to an academic journal. They want to know if you did what you set out to do and—if not—why you made changes. They will look at your trial registration and protocol, if publicly available or submitted with the trial report—comparing the information in the trial registry to that in the trial report and looking for consistency for important trial characteristics. Authors of systematic reviews will do the same when they include your trial—once published—in their review and assess bias, for example, in the selection of your reported results. 10

We encourage you to take the same approach as reviewers and editors when you write your trial report. Have the trial protocol open and the registration available when you write—generally use a copy-paste approach for important trial characteristics to increase transparency and consistency for two related work packages of the same research project ( figure 1 ). Sometimes the trial report will be flagged by plagiarism checkers that journals use because the methods sections are very similar. Ensure you reference previous work and consider presenting the argument for this approach in the cover letter and/or the trial report itself. The guide ‘Avoiding Plagiarism, Self-plagiarism, and Other Questionable Writing Practices: A Guide to Ethical Writing’ by Dr Miguel Roig is a helpful and detailed resource. 11 Roig made the case for more editorial flexibility when it comes to textual reuse of technical descriptions—especially for writers who do not have English as their first language. 12 Finally, check any author/publisher copyright agreement if you have published your trial protocol to avoid any copyright infringement.

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We encourage you to have the protocol open and trial registration available when you write. If you use a copy-paste approach, it will facilitate consistency between trial protocol, registration and report.

Using a copy-paste approach will help you report important trial items in the same order and with the same wording as used in the registration. Examples of important trial items include aim, selection criteria and outcomes. If you deviated from the plan (common and acceptable with a reasonable explanation) transparently report it and why. Many journals require that you upload the trial protocol as a supplemental file to the trial report. A copy-paste approach creates a strong link between these two documents and increases readability. If wording cannot be copied and pasted 100% for consistency, we suggest you check carefully if the meaning is still the same. For example, you may have come up with a better title after having revised the trial report many times, or you realised that the trial objective could have had better wording.

Writing your trial report

Structure: introduction, methods, results and discussion.

Most scientific journals prefer a trial report style that follows the IMRaD-structure (ie, I ntroduction, M ethods, R esults a nd D iscussion). 13 You can find useful generic information on how to structure scientific papers from the PLOS collection. 14 We provide additional information relevant to the different sections of a trial report below.

Crafting a ‘tempting title’

Declarative and descriptive titles are the typical types of titles a reader is likely to encounter in the sports & exercise medicine field. A declarative title declares the key message (often a key result; eg,’ Meniscus or cartilage injury at the time of anterior cruciate ligament tear is associated with worse prognosis for patient-reported outcome 2–10 years after anterior cruciate ligament injury: a systematic review’). 15 A descriptive title describes what the reader can expect to find in the trial report (often the type of study, the population or the outcome; eg’ Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 RCTs’). 16 When crafting a title for your trial report, consider whether you are aiming to engage the reader, inform the reader, or both, and if possible finalise the title with the design of your study.

Scientific writers can be creative without being frivolous, trivial or unscholarly/unscientific. A tempting title does not mean one has engaged in ‘spin’. 17 We recommend aiming for a declarative title where possible—the title is your chance to share a powerful first impression with your reader—although, we recognise you do not always have a choice. Adopting the engaging: informative style 18 offers a way to let your creativity flow, without straying too far from scholarly conventions and inviting the stroke of an obstinate editor’s correction pen. Here is one example:’ Running themselves into the ground? Incidence, prevalence, and impact of injury and illness in runners preparing for a half or full marathon’. 19

Your tempting title might comprise two, or even three, parts: (1) the hook: perhaps a play on words or a metaphor, (2) the key message, where you declare why the reader will want to read on or what she will find if she reads on, and (3) a key distinguishing feature of your trial report: perhaps a characteristic of the population, the type of trial (eg, double-blind superiority trial) or time frame for data collection). To facilitate correct PubMed indexing and identification, the CONSORT group 3 encourages authors to include the study design in the title (eg, ‘an RCT’).

The stylish academic writer: three suggestions to help you capture and engage your reader’s attention

Scientific writing and creative writing are not polar opposites. Our statement in the last section on tempting titles bears repeating: scientific writers can be creative without being frivolous or unscholarly. Like with your title, we recognise you may not always have a choice about some aspects of style (eg, some journals require third person perspective and forbid using first person pronouns like ‘ we measured quadriceps strength using an isokinetic dynamometer.’).

Suggestion 1: use concrete language and banish passive sentences

Consider replacing ‘There are numerous approaches to the quantification of training load’ with ‘There are at least three tools to measure training load’. Even more concrete is: ‘We describe three tools clinicians could use to measure training load in recreational runners’ because (1) your reader knows how many ways to measure training load she can expect to read about, and (2) she knows something about the population. She also knows who is doing what to whom: clinicians (who) are measuring (doing what) the training load of recreational runners (whom). Numbered or ordered lists help you organise your thoughts and convey a clear message to your reader.

Suggestion 2: write in active sentences that are driven by active vivid verbs

Even when your writing context is constrained or less flexible (or perhaps inflexible) given journal requirements, we encourage you to address your reader directly—with active writing. One can choose to write concise, clear, coherent sentences or one can choose vague, passive, verbose sentences. Which sentence holds your attention as a reader? Concrete language uses active verbs (eg, describe, explore, compete, measure), avoids abstract nouns (eg, quantification, conversation, completion, effectiveness, discretisation) and clarifies who is doing what, to whom.

Suggestion 3: comb your manuscript for be-verbs and replace them with active verbs

Forms of be, including was, were, been, being, are, is or shown, are also juicy targets for writers who are aiming to resurrect their writing. Passive verb constructions like ‘can be measured’ or ‘were shown’ weigh your writing down. Try replacing a few be- verbs in each paragraph with active, vivid verbs (eg, masquerade, prescribe, roll, shun).

Writing well is a deliberate, careful and considered process. It is a craft that requires time and practice. You will find writing resources and suggested reading on renowned Professor of Linguistics and scientific writing coach Helen Sword’s website. 20 Four of the five authors of the REPORT guide do not have English as their first language. In scientific writing, we use the three suggestions above. We also use a ‘how simple can you go’ approach to guard against major linguistic mistakes and to increase readability for readers whose first language is not English. In Lingard et al ’s excellent Writing Craft series, 21 they identify key grammatical challenges and offer practical tips for native Spanish, French, Dutch and German speakers who are writing in English ( table 1 ). 22

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Key grammatical challenges for Spanish, French, Dutch and German researchers writing in English

Three things to try:

Watch Professor Sword explain how to avoid nominalisations. 23

Run your writing through an online workout. 24

Train with some Wordcraft Workouts . 25

Abstract: the CONSORT-way

The trial report abstract is important because it will likely have many more reads than the full trial report. Most journals have a word limit for abstracts, and some have mandatory structure and headings. Each of these restrictions can pose a challenge when writing a clear, transparent and detailed abstract—you need to make every word count. 21 If journal formatting allows, use the CONSORT for reporting randomised trials in journal and conference abstracts. 26 It comes with an explanation and elaboration paper 27 as well as an abstract item checklist, which can be downloaded from the CONSORT website. 28 Preliminary work from the CONSORT group showed that all the checklist items can fit within 250–300 words. 27 The CONSORT website also has a sample study that implements the CONSORT checklist. 29 The sample study includes an example of how to write abstract results, which can be problematic. 30

When you state the trial framework, for example, ‘superiority trial’ it creates an excellent link to what follows in the abstract. It links to which intervention the authors hypothesise to be superior to the comparator (objective); the main outcome and time frame that this is assessed (primary outcome and endpoint); indication of risk of bias (randomised vs analysed, blinding, trial registration), indication of superiority (effect size, between-group difference in response for the primary outcome) and claim of superiority as hypothesised (conclusion). To avoid unintentional reporting 31 or spin 32 biases in the conclusion, we suggest you reserve the first line to conclude on your objective and corresponding primary outcome and use PICOT 33 as the framework (Population, Intervention, Comparator, Outcome, Time frame). For example, ‘Compared with intervention C (the comparator), the intervention of interest I was not superior in reducing O (primary outcome) at T (time frame) in P (population). We encourage you to then continue with secondary outcomes: ‘For the secondary outcomes X, Y and Z, we found that (…)’ ( figure 2 ).

We encourage you to create a strong link between the conclusion and the trial aim and hypothesis if you think ‘aim’, ‘hypothesis’ and ‘trial design’ when you write the first line of the conclusion.

If your trial was prospectively registered, we suggest you state this at the end 26 of the abstract as ‘Trial identifier: (number) followed by ‘(prospectively registered)’. If for some reason your trial was not registered before the first participant was included (prospectively/preregistered), we suggest you transparently report this at the bottom of the abstract as ‘Trial identifier: (number)’ followed by ‘(retrospectively registered)’. This is currently the editorial policy for all BMC journals when they consider retrospectively registered trials for publication. 34 In the main trial report we encourage you to explain the reason for this practice and state if important trial changes occurred after the trial began, as there will be no publicly available record of your research intentions. If you posted your trial report as an open access preprint, we encourage you to add the preprint information to the bottom of the abstract. In the REPORT guide, you will find an example of this use (more info about preprints below). It will help the reader find an open access version of your trial report and link the two documents via the digital object identifier (DOI) 35 ; ‘Preprint (open access): http://doi.org/ (doi number)’. We suggest you use a copy-paste approach for important abstract information, so that it is consistent with the trial registration and/or published protocol as well as main trial report document (eg, aim and conclusion).

For more information on abstract reporting: 21 27 36

Introduction: the ‘why’ of your trial

In this section, we encourage you to present the ‘why’, that is, an argument for why your trial is needed. If the ‘why’ is not clear to you and your coauthors, it will be difficult to convey it in a trial report. Readers are already motivated because they screened your title and abstract for relevance and results. However, the Introduction helps the journal’s reviewers and editors judge the importance of your trial report. It is therefore essential to making it interesting, while at the same time concise and describe the knowledge gap that your trial is intended to fill.

Your introduction should present the scientific background and rationale. 3 It should follow the background section of your protocol, as the reason for doing the trial has not changed. Thus, the introduction can more or less be copy-pasted from your protocol. During the planning and conduct of your trial, however, others may have published relevant research findings. They may support or oppose your results but should be mentioned. The introduction should include a summary of relevant studies as an up-to-date systematic review or at least include the latest published systematic review on your topic. It is important not to be selective in this literature review as it may mislead the reader, increase the risk of confirmation bias 37 or unintentionally communicate that the knowledge gap is larger or more important than it is. Consider letting the reader know that you have made steps to avoid this by stating that you have scrutinised all available evidence and use the best available evidence to inform the need of the trial: ‘The latest systematic review with meta-analysis on the effectiveness of (your intervention) on (your outcome of interest) concluded that (main finding). This is supported by two recent trial reports published after the systematic review by (author)’.

While the background information in a trial protocol oftentimes is very lengthy, the introduction part of a trial report can be shorter. Consider who will read your trial report and try to direct the introduction to that audience. For specialty journals it is not necessary to state general knowledge in the field. If you write about treatment of sports injuries and intend to publish in a sports medicine journal, it is unnecessary to write elaborately about the prevalence, costs, injury mechanisms or importance of treatment effectiveness. Readers of the journal will know this information already. Focus more on your trial rationale, specific research question, and aim. By cutting to the chase, you will save words that are better spent elsewhere.

End the introduction by stating the aim or the objective of your trial and include the hypothesis. Aims and hypotheses are not always easy to differentiate, but hypotheses are typically more specific and relate closely to the chosen trial design, outcome measures and statistical analysis plan (SAP). This is the most important part of the introduction. We suggest you copy/paste from the trial registry and/or published protocol for consistency ( figure 1 ). We also suggest using the copy/paste approach for abstract and main trial report so that the aim in the abstract is the same as the one in the main trial report.

For more information on systematic reviews to fully use previous research: 38 39

Methods: the ‘how’ of your trial

In this section, we encourage you to present the ‘how’ of your trial. What did you do in order to answer the ‘why’? The methods section is a detailed description of what was done and serves at least two main purposes: (1) to provide enough information to allow the reader to critically appraise and interpret the results, and (2) to convey as many details as possible so other researchers (in principle) will be able to replicate you trial entirely or in part. For clinical application of your trial results, it is important to give detailed descriptions of the population selection, assessment methods, and interventions. Other important aspects of the methods section are central for evaluating the scientific quality, validity and reliability of the trial.

Ideally, the methods section should be a replica of your trial protocol. But completing a trial without ‘bending the rules’ laid out in the protocol is practically impossible. It is therefore important to report any deviations and violations of the protocol. It is not a ‘scientific crime’ to deviate from the protocol, but it is important to report any deviation with potential bearing on your primary and important secondary outcomes (and thus on the interpretation of the entire trial). It is particularly important to declare ‘planned’ deviations, such as changes to eligibility criteria (eg, due to safety or slow recruitment), changes in instruments (eg, change of MRI-scanner due to breakdown). We suggest you report the deviations with reasons and describe what you did.

When you write your trial methods, imagine that your trial report 1 day will be scrutinised as part of a systematic review or clinical guideline. Reviewers will appraise your trial report on the lookout for flaws (or risks of bias). While you may have conducted your trial scrupulously (ie, with a low risk of bias), reporting can be incomplete. Reviewers may be uncertain about aspects of your trial methodology, which may mean they must downgrade the quality of your trial. We suggest you consult The Cochrane Handbook for Systematic Reviews of Interventions. 40 It provides detailed information on how to appraise individual trials, and provides you useful hints on what reviewers are looking for. For example, a reviewer may look for the phrase ‘sequentially numbered, opaque, sealed envelopes’ when assessing risk of bias for ‘Allocation concealment’. Knowing this, will help you clearly report how this was done in your trial.

For more information on how to report protocol deviations and risk of bias assessment: 40 41

Methods: outcomes

The CONSORT checklist items for ‘Outcomes’ ask you to report ‘Completely defined pre-specified primary and secondary outcome measures, including how and when they were assessed’ and ‘Any changes to trial outcomes after the trial commenced, with reasons’. 3 If you use a copy-paste approach, it will be easy to copy from your protocol and preregistered trial summary and paste into the trial report. It will create consistency with regards to, for example, number of outcomes, outcome hierarchy and wording. If for some reason you had to add or remove outcomes during the trial, we recommend you report this transparently, with reasons.

The COMPare trials project 42 team systematically checked every trial published in the top five medical journals between October 2015 and January 2016, with the purpose of searching for misreported findings and outcome switching. This team’s effort revealed a large degree of inconsistency in outcome reporting. 43 44 If for some reason, you had to make changes to your trial outcomes after the trial began, state this transparently and give reasons for the changes. If you plan to report collected outcomes in subsequent (secondary) trial reports, we suggest you state in the primary trial report that the outcomes were collected—consistent with the trial registry—and that you plan to report them in a subsequent report. This could be the case if you collected mechanistic and more exploratory outcomes in your trial, such a blood samples that await future advanced molecular analysis. Stating that these were collected will help you avoid misreporting of outcomes. The COMPare trials project 42 state in their Frequently Asked Questions-section: ‘Question: What if some outcomes are reported in a different publication? Answer: This is fine, as long as this fact has been declared in the trial publication. For example, if a trial says here we are reporting A B and C, in a subsequent paper we will report X Y Z then the outcomes X Y Z are not considered as unreported, and they are removed from the denominator. ’. 45

For more information on how to report trial outcomes: 3 42 46

Methods: interventions

Proper reporting of interventions is especially important for clinical application of your trial interventions, correct interpretation of your trial results, comparison with other trials (with similar interventions) and ability to inform new research questions. Unfortunately, intervention reporting is generally poor. 47 To help you report your interventions, The Better Reporting of Interventions: Template for Intervention Description and Replication checklist was developed. 48 It will help you make a complete and thorough generic description of the interventions. You may also need to consult a more intervention-specific guide or reporting checklist, such as the Consensus on Exercise Reporting Template for exercise trials. 49 We suggest you describe any ‘usual care’ or other comparator intervention using the same standards and checklists. For some comparators, reporting checklists have been developed—one was just developed for placebo and sham controls. 50 You may already have published a detailed description of your intervention and comparator as part of a published protocol. In case changes were made to the intervention or its delivery during the trial, consider if the description needs to be updated and submitted with the trial report as supplemental material. It will help both replication and clinical implementation of your trial results. In case you have not already published a detailed intervention description, consider publishing it as supplemental material to your trial report. It will help you if the journal has a word limit for the main document.

For more information on how to report trial interventions: 48 49

Methods: sample size

This sample size paragraph is intended to outline how you, in the trial planning phase, ensured that the trial would have the required statistical power to identify whether a difference of a particular magnitude (the target difference) exists for the primary outcome. It is also intended to show that you did not include any extra participants than were needed for the trial. As you did all the thinking already, it should be feasible to copy/paste from the trial protocol. The basics of calculating sample size are covered in substantial detail in the PREPARE Trial guide. 1

For more information on how to determine and report the target difference and sample size estimation for a trial: 51

Methods: statistical analyses

The problem of poor statistical reporting is long-standing, widespread, potentially serious and yet is largely unsuspected by many readers of the biomedical literature. 52 General guidance on how to write SAPs is now available 53 and provides recommendations for a minimum set of items that should be addressed for clinical trials before analysing data. 53 If you have not written a specific SAP as part of the trial protocol, 1 we recommend that you consult a biostatistician and write one before viewing any data or starting the analysis.

An SAP ensures that the statistical methods are reported in sufficient detail to enable a knowledgeable reader (with potential access to the original data) to assess the appropriateness of the chosen statistical methods and the underlying assumptions, and to verify your reported results. In a SAP, the statistical methods are often described in great detail, and a complete copy-paste approach may be too much (given that most journals have restrictions on manuscript length). We therefore recommend always submitting the SAP (with final date on cover page) as supplemental material so that editors, peer reviewers and other readers can take a deeper dive into the statistical methods.

In the main text, we encourage you to give an extract of the primary statistical analyses (from the SAP). If you have stated a clear objective, the reader will be able to understand the primary purpose of the trial and what to expect to see next. We recommend that you describe fully the main methods for analysing the primary and key secondary objectives of the trial. It is common to analyse the data set under different assumptions—sensitivity analyses—to assess the robustness of the primary analyses. These are typically based on different strategies for handling missing data or analyses of different trial populations (eg, the per protocol population which is potentially biased but still informative). We recommend you carefully describe these strategies. Excellent educational resources exist to assist you. They include the CONSORT explanation and elaboration paper, 3 the SAMPL guidelines for statistical reporting, 54 and the recently developed Checklist for statistical Assessment of Medical Papers statement. 55

For more information on how to report statistical analyses for a trial: 3 54 55

Results: attrition

Attrition can introduce bias in your trial results if the characteristics of participants who are lost to follow-up differ between the randomised groups—especially if the differing characteristic is related to trial outcome measures. 56 If you use the CONSORT flow diagram to illustrate the trial profile, we suggest you report the demographics of the participants included in the intention-to-treat population with descriptive statistics for each group. We encourage you to create an overview by preparing a classic table 1 of baseline characteristics using the outline from the CONSORT explanation and elaboration paper. 3 You may also find it useful to supplement with table items as suggested by Dumville et al 56 and attach as a baseline appendix.

Reviewers will sometimes ask for results of statistical testing for baseline differences. The recommendation from the CONSORT group is clear: ‘Such hypothesis testing is superfluous and can mislead investigators and their readers. Rather, comparisons at baseline should be based on consideration of the prognostic strength of the variables measured and the size of any chance imbalances that have occurred’. 3 It means you should subjectively judge if any differences between groups that will occur by chance due to randomisation is of a magnitude that you think is clinically relevant.

For more information on how to report attrition: 56

Results: focus on the main analysis and between-group differences

Correct reporting of the results of the statistical analyses includes explicit estimates presented with appropriate indicators of measurement error or uncertainty, such as 95% CIs. Randomised trials are designed to analyse differences between groups, and the results should focus on these—not on changes within groups. However, it is helpful for transparent reporting and interpretation to present the estimates in each group. We strongly recommend that you avoid reporting only statistical hypothesis testing (eg, such as P values), as they do not contain much information and do not convey important information about effect sizes or precision of estimates. When you report p values, we recommend you report actual p values, rather than p<0.05, unless the value is very small (eg, p<0.0001).

We suggest you report your primary analyses first and hierarchically (primary outcome before secondary and other outcomes). This will most likely follow the hierarchy outlined in your trial protocol and SAP. By being consistent and use a copy/paste-approach, you will help the reader assess if you followed your SAP. We recommend you avoid interpretations or interpretative language in the results section, but instead help the reader by providing a direction of the results and whether it favours one of the groups. In cases where discrepancies between analysis sets occur among the primary analyses and the sensitivity analyses, we suggest you highlight them in the text. You may also need to devote more attention to interpreting the collective results because the confidence in the individual analyses is reduced.

During your data analyses, new and exciting ideas may arise, as well as unexpected findings that you did not consider during planning. Such results can be important and foster significant scientific advances. However, consider that your trial design may not support confirmatory analyses or statements of such findings, and it is important to state (both in the Statistical methods section and in the Results section) that these were not prespecified. Related to this topic is the situation where a peer reviewer asks for additional analyses of your data set; that is, frequently referred to as the ‘peer review pressure test’. These are often valuable and reasonable requests, but should very rarely replace the original analytical strategies, unless there are fundamental flaws in the trial design and/or the chosen analyses do not reflect the experimental design. We suggest that post hoc analyses requested by peer reviewers are reported in supplemental files and included in a response letter to the reviewers when submitting a revised manuscript.

For more information on how to report the results of statistical analyses for a trial: 54 55

Results: transparent illustration of your data

Your tables and figures should ideally be able to stand alone (eg, in presentations and lectures). It is valuable to provide brief summaries of the statistical methods used (eg, as foot notes to tables and figures). The CONSORT checklist and explanatory paper have great examples and descriptions of how to make certain illustrations. On the CONSORT website, you will find a flow diagram template freely available for download. 28 We suggest you add some additional information to the flow diagram, including numbers of participants included in the different analyses (eg, intention-to-treat and/or available case analysis) and number of imputations made for missing data, if applicable. For an example, please see Lysdal et al 57

Include specific information on your sampling strategy at the top of the flow diagram because it will facilitate interpretation of the trial findings with regards to clinical relevance. Consider reporting the total number of potentially eligible participants during the trial recruitment period and how many of these were assessed for eligibility, instead of only reporting the number of individuals assessed for eligibility. It allows the reader to judge how well the trial population represents all patients seen at the recruitment site while the trial was running. Because this issue relates to external validity it is important—but it is especially important if the trial findings have major implications for current clinical practice. Please see Clausen et al 58 for an example of how the number of potentially eligible participants can be incorporated into the trial flow chart. Please also see the rapid responses 59 to the FIMPACT 60 trial for a discussion of the importance of including the number of potentially eligible participants when trial findings have great implications for clinical practice.

Results may sometimes merit a figure in the form of a graph. Many bar or lines graphs—based on continuous data with different distributions—can lead to the same bar or line graph ( figure 3 ). 61 Unless you include raw data in the graph, most information will be invisible to the reader. We encourage you to making it visible by using scatter plots instead of bar charts.

Many different datasets can produce the same bar graph. The figure and legend are modified from Weissgerber et al 61 https://doi.org/10.1371/journal.pbio.1002128 under the terms of the creative commons CC by 4.0 license https://creativecommonsorg/licenses/by/40/ .

For more information on how to effectively use tables and figures in scientific papers: 61–63

Results: harms

When new healthcare interventions are studied, researchers tend to focus more on efficacy than safety. There is poor reporting of harms in trial reports across many clinical areas, 64 which makes it difficult to obtain a true estimate of the benefit-harms ratio. The CONSORT extension for harms 65 was developed to improve reporting of harms-related data in trials. Because the main focus of the CONSORT checklist is efficacy reporting, we suggest you supplement your trial reporting with the CONSORT extension for harms 65 to improve reporting of harms-related data.

For more information on reporting of harms-related data: 65

Discussion: consider clinical relevance and confirmation bias

The CONSORT checklist 46 holds the overall framework for the discussion and items you should address, but scientific journals may have additional requirements. We suggest you use the CONSORT checklist to structure the discussion, and supplement with requirements from your target journal, if needed. We would like to highlight two important items: clinical relevance and confirmation bias.

We suggest you focus on the primary analysis and outcome. Your trial was designed first and foremost to provide a reliable answer in terms of the hypothesis for this analysis and outcome. The test statistics will determine if the difference between groups is statistically significant. Judging and discussing whether a statistically significant difference between groups is also clinically relevant should be easy at this point. You will already have argued in your trial protocol and sample size paragraph what minimum theoretical difference between groups you consider clinically relevant and why. Now that you have the observed difference between groups, the main issue is to compare the two and discuss the size of the observed effect. An important aspect of this discussion is the precision of the observed effect. In general, the larger the sample size of your trial, the greater the precision of the observed effect. The precision is reflected in the 95% CI of the observed effect. The greater the precision, the smaller the 95% CI and vice versa. We suggest a balanced discussion of the clinical relevance of the observed effect to include both its size (in relation to the predefined minimal clinically importance difference) as well its precision. It will help you avoid unintentional confirmation bias (please see below).

Biases come in many forms and can affect healthcare in many ways. There may be biases that you want to acknowledge specifically under ‘Limitations’ in the discussion because you think they may have influenced trial procedures or outcomes. We suggest you consider your own ‘confirmation bias’ when writing the discussion—or the whole trial report for that matter. As stated by the Catalogue of Bias Collaboration 37 : ‘Confirmation bias occurs when an individual looks for and uses the information to support their own ideas or beliefs. It also means that information not supporting their ideas or beliefs is disregarded.’ Being researchers, we argue that most of us unintentionally wish for our intervention to be superior to the comparator for several reasons: (1) we want to help patients by advancing the field, or (2) we think it will bring promotion or other academic reward. By being intentionally aware of our own confirmation bias, we can better stay clear of issues such as unintentional secondary analysis emphasis (spin) and selective referencing of work that support our own findings.

For more information on statistical significance, clinical relevance, spin and confirmation bias: 17 37 66

Conclusion: what was your trial designed to test first and foremost?

When you write the trial report conclusion, we encourage you to think ‘aim’, ‘hypothesis’ and ‘trial design’. What was your trial designed to test primarily and how was this formulated in the aim? Was it to assess if the intervention of interest was better than (superiority trial), no worse than (non-inferiority trial), or whether it was as equally effective as (equivalence trial) the comparator? Using this line of thinking will help create a strong connection between aim, hypothesis and conclusion. It will also help you conclude only what the trial data support. If the aim of a superiority trial was ‘To investigate if I (Intervention of interest) is superior to C (comparator) in improving O (primary outcome) at T (timepoint) in P (population) and there was no difference in response between groups, the conclusion could start with: ‘Compared with C (comparator), I (Intervention of interest) was not superior in reducing O (primary outcome) at T (time point) in P (population). A very common mistake is to interpret the absence of evidence of superiority as evidence of equivalence or non-inferiority and conclude that the intervention of interest and comparator were equally effective or no different (for more details, please see refs 1 67 ).

Having addressed the main hypothesis, analysis and outcome the trial was designed to assess, we encourage you to proceed with interesting secondary analyses and—at the same time—inform the reader about the increase in risk of bias for these analyses: ‘For the secondary outcomes, X, Y and Z, we found that (………).’. When you conclude first on the primary analysis, you minimise the risk of unintentional reporting 31 or spin 32 biases. If your trial was more exploratory than confirmatory 1 —or had a flat outcome hierarchy with no single primary outcome—you may want to consider finishing the conclusion by acknowledging this. For example, ‘This finding needs replication in future trials’. Readers will often be interested in your thoughts on the implications of your trial findings. Some journals allow implication statements and others do not. If you do write about implications, we suggest you make it clear that this part of the conclusion is you speculating and conveying your expert opinion with phrasing like: ‘These findings may have implications for (……) insofar as (……).’. When you have finished writing the conclusion, check that it matches the trial aim and conclusion in the abstract.

Sharing research data

Depending on national legislation, you may or may not be able to share the raw trial data. Data sharing is one way of increasing transparency and maximising the trial participants’ research contribution by making the data they provided broadly available for secondary research purposes. 68 69 Data sharing is also expected by some non-private funding bodies. 70 If you can share your trial data, there are some things that you may want to consider. They include practical steps to data management, anonymisation and storage.

For more information on data sharing: 71–74

Alternative avenues for disseminating your research

When you are ready to submit your trial report to a scientific journal, consider publishing a preprint. A preprint is scientific work that has not undergone peer review and is not published in a scientific journal. 75 It is typically a manuscript draft that is ready to be submitted to a journal for peer review. A preprint can also be an earlier manuscript version that you want to make public. One advantage of publishing a preprint is that it is assigned a DOI, 35 which makes it searchable. Most publishers allow preprints, 76 but we suggest you check the preprint policy of the scientific journal that you aim to submit your trial report to. Elsevier states: ‘Preprint: Authors can share their preprint anywhere at any time. If accepted for publication, we encourage authors to link from the preprint to their formal publication via its Digital Object Identifier (DOI). Millions of researchers have access to the formal publications on ScienceDirect, and so links will help your users to find, access, cite, and use the best available version. Authors can update their preprints on arXiv or RePEc with their accepted manuscript. Please note: Some society-owned titles and journals that operate double-blind peer review have different preprint policies . ’. 77

Submission to preprint servers is typically free and it creates an open access option, even if you end up publishing your trial report behind a paywall. 78 It allows you to have crowdsourced feedback and to promote your open access research early (eg, during the period of peer review). Based on feedback, you can update your preprint version when you revise your manuscript. Some (but not all) publishers even allow you to update your preprint to the accepted (non-type set) manuscript version with proper reference to the journal publication. Please check the publisher’s preprint policy for guidance. If you look at the bottom of the abstract of this guide, you will see a link to an open access preprint. Had this guide not been published open access, an interested reader could see from the PubMed abstract where to find an open access full text (preprint).

For more information on preprints: 75

Researchers are familiar with social media platforms like Twitter for sharing new scientific content. When posting to social media, make space to include (1) the DOI 35 and (2) an image—two simple steps to help make your post visible to attention metrics-aggregators like Altmetric and capture the viewer who might otherwise scroll past your post. Across research areas, the Altmetric score has been associated with number of citations, journal impact factor, press releases and open access status. 79 80

Have you considered other forms of media? Researchers who embrace the rich ecosystem of digital media might find themselves partnering with clever infographics designers or using free (or freemium) websites to design their own. Consider writing for trusted outlets like The Conversation 81 —a news organisation that is dedicated to sharing information from the academic and research community, direct to the public, with ‘academic rigour and journalistic flair’. Sports medicine and sports physiotherapy journals including British Journal of Sports Medicine and Journal of Orthopaedic & Sports Physical Therapy have blogs dedicated to reaching a non-academic audience of clinicians, patients, athletes and coaches.

Consider approaching your academic institution’s media and communications department or press office. The staff are typically pleased to work with you to shape a press release, distribute the press release to mainstream media services, and connect with media contacts. Media and communications departments also share helpful tips for making your research visible to the media. 82

After publishing the trial report

After your trial report is published, consider (1) Is the ‘Trial status’ up to date in the trial registry? (2) Do I need to update the trial registry with a link to the published trial report and/or raw data if shared? (3) Do I need to report to funding bodies on the accomplished milestone (publication)? (4) Do I have a plan for disseminating the trial results other than the primary trial report? (5) Do I have a plan for storing and filing essential trial documents and data that adheres to national guidelines?

We hope the REPORT guide is helpful and a valuable supplement to ‘first choice’ trial reporting tools, such as CONSORT. We aimed to incorporate tacit knowledge about reporting, and flag issues we have struggled with. Quality decisions in healthcare depend on reliable evidence of treatment effects. Good research reporting practice does not cure ‘diseases’ that arise from poor research methodology—it helps the reader see the illness and appraise the research quality. No research is perfect. We do not profess to produce and report perfect research that is free from ‘disease’ 100% of the time. We implore all researchers to commit to conducting (and reporting) clear and transparent research.

What is already known

Reporting of clinical trial research varies and is known to be poor.

What are the new findings

The REPORT Trial guide is a one-stop, ‘how-to’ implementation guide and directory that holds tacit knowledge and references to first-choice sources of information about effective and transparent trial reporting (eg, CONSORT).

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study does not involve human participants.

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Twitter @TBandholm, @KThorborg, @clare_ardern, @drrchristensen, @henriksen_mh

Contributors Conception and design: TB. Drafting and critical revision for important intellectual content: all authors. Final approval of manuscript. all authors. Accountable for all aspects of the work: all authors.

Funding CLA has received research salary support for work in return to sport from the Australian National Health and Medical Research Council (Early Career Fellowship APP1109779), Swedish Research Council (2015-03687) and Swedish Research Council for Sport Science (Postdoctoral fellowship D2018-0041), and is Editor-in-Chief of JOSPT (Journal of Orthopaedic & Sports Physical Therapy). The Parker Institute, Bispebjerg and Frederiksberg Hospital is supported by a core grant from the Oak Foundation (OCAY-18-774-OFIL).

Competing interests CLA was Deputy Editor (Systematic Reviews) for BJSM from 2016 to 2018 and is currently the Editor-in-Chief for JOSPT. TB and KT are BJSM editorial board members.

Provenance and peer review Not commissioned; externally peer reviewed.

Read the full text or download the PDF:

Sample Medical Report Format: A Comprehensive Guide for Professionals

The Importance of a Sample Medical Report in Healthcare Documentation

Healthcare documentation is a critical aspect of medical practice, serving not only as a record of patient encounters but also as a pivotal communication tool among healthcare providers. A sample medical report is particularly important as it sets a standard for documentation, ensuring consistency and clarity in the patient’s medical records. By illustrating the ideal format and type of information that should be included, a sample report serves as a benchmark for quality, which is essential for maintaining a high standard of healthcare delivery. It acts as a guide for practitioners to succinctly capture patient history, diagnosis, treatment plans, and follow-up care, which is paramount for delivering coordinated and effective patient care.

In an environment where the precision of information is life-critical, a well-structured sample medical report can greatly decrease the margin for error. It ensures that pertinent patient details are not omitted, facilitating an accurate and comprehensive understanding of the patient’s medical journey. Here are some key reasons why a sample medical report is significant:

Welcome to the medical revolution, where words become your most powerful ally

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– Consistency: It standardizes the reporting format across different healthcare professionals and institutions. – Accuracy: Serves as a checklist to ensure all relevant data is included, reducing the likelihood of missing crucial information. – Education: Assists in training new healthcare practitioners in preparing medical reports. – Legal and Regulatory Compliance: Helps in adhering to the documentation standards required by healthcare regulations and laws.

The use of a sample medical report in healthcare also complements the integration of AI-powered tools, like the services offered by ScribeMD , which are designed to automate and enhance the efficiency of medical note-taking. With AI assistance, the consistency and structure provided by a sample report can be replicated across numerous patient interactions, thereby ensuring alignment with best practices in medical documentation. Moreover, the sample report acts as a foundational template for AI programs to understand the essential elements of patient care records, thus improving the accuracy of data entry and retrieval in electronic health systems.

Additionally, in the inevitable instance of patient transitions between facilities, a sample medical report provides a universally understandable documentation format that minimizes misinterpretations that can lead to medical errors. The continuity of care is paramount, and standardized reports help in orchestrating seamless transitions by offering a clear and concise summary of the patient’s medical history and current health status, which is easily decipherable by incoming medical teams. Such samples can also serve as teaching tools, empowering medical students and residents with the knowledge of proper documentation techniques pivotal for effective patient management.

– Enhances continuity of care. – Simplifies information transfer across healthcare providers. – Reduces risk of clinical errors due to miscommunication. – Provides a teaching resource for future healthcare professionals.

Key Elements of an Effective Sample Medical Report

Constructing an effective sample medical report requires a meticulous approach, as it stands as a pivotal document for patient care, legal scrutiny, and medical history. A quintessential report must embody clarity, accuracy, and comprehensive detailing of the patient’s condition and the care provided. Critical information starts with correct patient identification details, which should include the patient’s full name, date of birth, and a unique identification number. This data ensures that there is no mix-up of patient information, which is vital in delivering personalized and error-free care. Following this is a precise documentation of the patient’s medical history, allergies, current medications, and pertinent family history—all key components that can significantly influence diagnostic decisions and treatment plans.

• Patient Identification: Name, Date of Birth, ID Number
• Medical History: Past and Present Conditions
• Medication and Allergies: Current Regimen and Reactions
• Family History: Relevant Hereditary Conditions

The physical examination findings and diagnostic test results are further essential elements, providing a factual basis for the patient’s current health status. The clarity of these results is critical, as they inform the subsequent steps in patient care. Additionally, accurate and detailed accounts of treatments provided or planned, including dosages of medication prescribed and any procedures undertaken, are invaluable for continuity of care. This information should not only be precise but also written comprehensibly to be accessible to a multi-disciplinary team that may include specialists or pharmacists, who all play a pivotal role in the patient’s health management.

• Examination Findings: Vital Signs, Observed Symptoms
• Diagnostic Tests: X-Rays, Blood Tests, etc.
• Treatment Documentation: Medications and Procedures

Moreover, an effective report provides a clear narrative of the assessment and plan of action tailored to the patient. This includes a conclusive diagnosis, a plan detailing the approach for treatment, and recommendations for follow-up care. The prognosis, when included, gives insight into the expected outcomes and potential complications, helping patients and their families to understand the road ahead. Often overlooked yet equally important is the documentation of the patient’s consent and understanding of the outlined treatments and procedures. This transparency fosters trust and is a critical component of ethical medical practices. Thus, the drafting of medical reports is not just a perfunctory task but a nuanced practice, where the articulation of every medical detail counts.

In the age of digital health records, integrating advanced technological solutions such as AI-powered digital scribing tools can elevate the quality of medical reporting to new heights. These digital scribes assist in crafting reports that hit all the key elements with great precision, all while reducing the administrative load on healthcare providers. This allows for more efficient healthcare delivery and a heightened focus on patient-centric care, ultimately contributing to better health outcomes and patient satisfaction.

How to Interpret a Sample Medical Report: A Guide for Medical Professionals

Interpreting a medical report accurately is critical for medical professionals to ensure effective patient care and communication. A medical report provides a comprehensive account of a patient’s medical history, comprising observations, diagnostics, treatments, and responses. To accurately decipher the contents, medical professionals must be adept at extracting key information and translating any clinical terminology into clear, actionable insights. As health records become increasingly digitized, the drive towards utilizing technologies like AI-powered digital scribes is amplifying the urgency to adapt to new methods of report interpretation.

The first step in interpreting a medical report is to review the patient’s identifiable information, ensuring that the report corresponds to the correct individual. Subsequent sections typically delineate the patient’s present complaints, medical history, physical examination findings, results from laboratory and imaging studies, diagnoses, and treatment plans. For a more structured approach, here is a condensed breakdown:

– **Identifiable Information:** Verify patient name, date of birth, and report date. – **Clinical History:** Distill past and present medical conditions. – **Physical Examination:** Note any significant findings or deviations from the norm. – **Investigative Results:** Assess laboratory tests, X-rays, MRIs, etc. – **Diagnosis:** Identify the medical condition(s) diagnosed. – **Management Plan:** Review prescribed treatment and follow-up.

In-depth analysis and interpretation of each section are key for holistic understanding. For instance, laboratory findings can signal a variety of conditions that may not appear obvious at first glance. Highlighting abnormalities and variations from previous results are significant cues toward the changes in a patient’s health status. Moreover, nuances in imaging interpretations may require correlation with clinical symptoms to derive an accurate assessment. The advancement of AI in healthcare, especially through platforms like Scribemd.ai, promises to assist healthcare professionals by streamlining these processes and providing real-time, accurate interpretations of medical data. The aid of a digital scribe can thus enhance precision in diagnosis, and in turn, patient outcomes.

In discerning the diagnosis and prescribed treatments in a medical report, it’s imperative to evaluate the rationale behind each decision. A meticulous review of the presenting symptoms, examination findings, and investigations should lead to a diagnostic conclusion that seamlessly dovetails with the treatment plan. Ensuring continuity in this logical progression underscores competent report assessment. With the synergy of digital transcription and AI assistance , the scope of error narrows, enabling healthcare providers to focus more emphatically on patient care, rather than the mechanics of medical documentation.

– **Clinical Synthesis:** Integrate all information to support the diagnosis. – **Rationale:** Understand the reasoning behind treatment choices. – **Treatment Efficacy:** Monitor response to treatment for future visits. – **Follow-Up:** Recognize recommended next steps or referrals.

Undoubtedly, as medical reports become ever more complex, the value of having an efficient, reliable system that supports medical professionals in the interpretation process cannot be overstated. The integration of cutting-edge AI like digital scribe technology is revolutionizing the field by providing such support, refining the accuracy of medical documentation, and maximizing the time healthcare providers can dedicate to their patients. This synthesis of technological sophistication and medical expertise is setting a new standard for patient care and report interpretation.

Utilizing AI to Enhance the Quality of Sample Medical Reports

The advent of artificial intelligence (AI) in the healthcare sector has revolutionized the way medical professionals approach record-keeping and documentation. With meticulous precision, AI technology assists in crafting high-caliber sample medical reports , setting a new benchmark for data accuracy and consistency. This is especially important in the medical field because sample reports often serve as educational tools and references for healthcare providers, students, and coding professionals. By integrating AI such as ScribeMD s AI-powered digital scribe, practitioners are able to generate exemplary reports that can significantly improve patient care and training methods.

One of the paramount ways AI is enhancing sample medical reports is through its exceptional analyzing capabilities . AI systems meticulously scrutinize vast amounts of data, recognizing patterns and anomalies that might escape the human eye. As a result, these systems can suggest accurate diagnostics, prognostics, and treatment plans in reports. They also retain and adapt from each interaction, continuously advancing the standard and reliability of medical documentation.

• Diagnostic Accuracy: AI algorithms can interpret complex medical information, leading to more precise diagnosis documentation.
• Consistency Across Reports: Automated templates and checks ensure uniformity in the structure and content of medical reports.
• Cutting-edge Learning: AI’s machine-learning component allows it to evolve by absorbing new medical data and case studies.

Moreover, by automating routine elements of medical reporting, AI frees healthcare practitioners from the tedium of manual documentation. This gives doctors more time to dedicate to patient care, rather than being bogged down by paperwork. Crucially, AI not only automates but also enhances the process by minimizing human error, which is pivotal in a field where precision is synonymous with patient safety. With AI’s assistance, the consistency and comprehensiveness of sample medical reports are markedly improved, making them invaluable resources for medical training and reference. In the end, the true impact of AI in improving sample medical reports is two-fold: it elevates the quality of healthcare documentation while simultaneously empowering medical professionals to prioritize patient engagement and care.

• Error Reduction: AI’s precision significantly diminishes the chance of human error in medical reports.
• Time Efficiency: Automated note-taking accelerates the documentation process, allowing for more patient-focused health care provision.
• Patient Safety: Enhanced accuracy in reporting directly contributes to improved patient outcomes and safety.

Accessing Professional Sample Medical Reports with Scribemd.ai

For medical professionals eager to streamline their workflow, Scribemd.ai offers an invaluable resource: professional sample medical reports. These samples are more than just templates; they are meticulously crafted documents that serve as a guiding framework for creating thorough and structured medical notes. By examining these carefully composed examples, physicians and healthcare providers can better understand how to efficiently document patient encounters, diagnoses, and treatment plans in a manner that is both comprehensive and compliant with medical coding standards.

The sample reports provided by Scribemd.ai focus on illustrating best practices in medical documentation. Each sample is designed to capture the essential elements of patient care encounters, which can include:

• Patient demographics and history
• Chief complaint and symptoms
• Clinical observations
• Diagnostic test results
• Diagnoses and treatment plans
• Follow-up care instructions

Access to these professional samples empowers healthcare providers to gain insights into the articulation of complex medical information, ensuring clarity and coherence. The samples can be easily adapted to various medical specialties, giving doctors a tailored experience that directly aligns with their specific practice needs. The improvement in documentation quality not just aids in maintaining a more organized patient record system but also enhances patient care by ensuring that vital health information is clearly communicated among the healthcare team.

Furthermore, with Scribemd.ai’s advanced AI capabilities , these sample reports are continuously updated to reflect the latest in medical guidelines and regulatory requirements. Healthcare professionals can trust that the knowledge they are acquiring from these reports is up-to-date, allowing them to stay at the forefront of medical documentation practices. The integration of these high-quality samples into Scribemd.ai’s digital scribe system makes the process of medical note-taking smoother, reducing the risk of error, and easing the administrative load on practitioners.

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How to write a medical case report

• Related content
• Peer review
• Seema Biswas , editor-in-chief, BMJ Case Reports, London, UK ,
• Oliver Jones , student editor, BMJ Case Reports, London, UK

Two BMJ Case Reports journal editors take you through the process

This article contains...

- Choosing the right patient

- Choosing the right message

- Before you begin - patient consent

- How to write your case report

- How to get published

During medical school, students often come across patients with a unique presentation, an unfamiliar response to treatment, or even an obscure disease. Writing a case report is an excellent way of documenting these findings for the wider medical community—sharing new knowledge that will lead to better and safer patient care.

For many medical students and junior doctors, a case report may be their first attempt at medical writing. A published case report will look impressive on your curriculum vitae, particularly if it is on a topic of your chosen specialty. Publication will be an advantage when applying for foundation year posts and specialty training, and many job applications have points allocated exclusively for publications in peer reviewed journals, including case reports.

The writing of a case report rests on skills that medical students acquire in their medical training, which they use throughout their postgraduate careers: these include history taking, interpretation of clinical signs and symptoms, interpretation of laboratory and imaging results, researching disease aetiology, reviewing medical evidence, and writing in a manner that clearly and effectively communicates with the reader.

If you are considering writing a case report, try to find a senior doctor who can be a supervising coauthor and help you decide whether you have a message worth writing about, that you have chosen the correct journal to submit to (considering the format that the journal requires), that the process is transparent and ethical at all times, and that your patient is not compromised in your writing. Indeed, try to include your patient in the process from the outset, and always gain consent.

A case report is the first line of medical evidence, and over time has become an important medium for sharing new findings (box 1). High quality case reports successfully bring together the various domains of medicine such as physiology, pathology, and anatomy. Using the patient as the focus, case reports provide a clinical “coat peg” on which to hang this knowledge.

Box 1: Notable case reports through the ages

Many case reports have changed the way clinicians view health and disease. For example, in 1861 the French surgeon Pierre Paul Broca reported the case of a dysphasic patient nicknamed “Tan”—owing to his inability to say any other words. After Tan’s death, Broca did an autopsy and discovered a syphilitic lesion in the frontal lobe of the brain, leading to the hypothesis of a speech centre in the brain—later known as Broca’s area. 1 Other notable case reports have documented the discovery of the Bence-Jones protein, 2 the first descriptions of Parkinson’s disease, 3 and AIDS. 4

Choosing the right patient

We can learn from all patients, but choose a patient from whom there is something new to learn. Search the literature and decide whether the topic you want to discuss, whether clinical or non-clinical (a radiological or microbiological finding, for example), has already been well discussed.

Your patient should ideally be someone who is not simply a willing participant in this process but someone who wants their story to be told to educate students, doctors, and other patients. Many journals have an option for patients to contribute to the manuscript.

Choosing the right message

Rare diseases are not in themselves a reason to write up a case, but unusual presentations of a common disease are important to communicate to the medical community. Early or subtle signs and symptoms that are easily missed are important for us to learn from. Indeed, the learning value of your case is the single most important factor in determining whether it is likely to be published.

Have in mind the journal that you want to submit your manuscript to before you begin to write. Your case and the message should fit with the style of the journal, whether a specialist journal, a case reports journal, or a journal that publishes case presentations in different formats. This may include question and answer formats, quizzes, or even interactive online educational formats useful for exam revision—for example, Endgames ( The BMJ ), Epilogue ( Archives of Disease in Childhood ), or Images ( New England Journal of Medicine ). These adapted formats are important, as most of these journals no longer accept case reports written in their traditional format.

Also, be careful in your claims about new diseases and new treatments. Case reports cannot make claims about the efficacy of novel treatments on the basis of individual cases and limited follow-up time. The most important message is a new or novel learning point—that is, the educational message.

Before you begin

Once you have chosen your patient and discussed with them what you would like to write, show them the case report so that they may give informed consent to your manuscript submission and familiarise themselves with the website.

It is important that a patient understands how their case will appear online or in print and that they truly give informed consent. You should do this under the supervision of the senior doctor who is the supervising coauthor of your manuscript; ideally, the senior doctor would obtain consent.

Writing the case report

Case presentation.

Begin with the case presentation (box 2): describe your encounter with the patient, their symptoms, and their signs. You should already have an idea what your take home messages will be. If the journal presentation of the case report allows, you can write these take home messages as bullet points (box 3).

Box 2: Case presentation

Acute pancreatitis and severe hypertriglyceridaemia masking unsuspected underlying diabetic ketoacidosis.

After 48 hours of anorexia, nausea, and non-bloody vomiting at home, the patient presented to her local hospital, where the diagnosis of moderate acute pancreatitis was made, based on an abdominal computed tomogram and ultrasound and serum chemistry. Ongoing symptoms, including left upper quadrant, 7/10 stabbing pain with generalised abdominal cramps, led to her transfer to the closest tertiary hospital for further management.

On admission to the tertiary hospital, the patient was treated as having uncomplicated pancreatitis. Immediate management included intravenous rehydration therapy, antiemetics, and narcotics for pain control with further orders for nothing to be ingested until the patient was re-evaluated. Initial assessment of the patient showed a temperature of 37.3ºC, heart rate 110 beats/min, blood pressure 126/68 mm Hg, respiratory rate 14 breaths/min, and oxygen saturation 98% on room air. She had a normal body habitus and was not in distress; however, she had a moderate amount of abdominal discomfort. Her physical examination showed no xanthalasmas or skin eruptions, nor was a fruity odour detected. Her gastrointestinal examination showed diffuse tenderness, with a soft, non-distended abdomen. Also, no organomegally was noted. Other than tachycardia, her cardiorespiratory examination was unremarkable with the notable absence of tachypnoea.

The patient was previously healthy without any medical history or surgical history. Her medication list was limited to the oral contraceptive pill (ethinyl oestradiol, norgestimate). The patient described only occasional social alcohol consumption (none within the last week) and no binge drinking or recreational drug use in the past. There were no recent surgeries, gastrointestinal endoscopic procedures, or abdominal trauma. She denied fever, chills, rigors, or recent unintended weight loss. There was no history of polyuria or polydipsia.

She did not have any prodromal abdominal symptoms There had been no similar episodes previously. There was no family history of dyslipidaemias, pancreatitis, or gallstones. Her family history was relevant for rectal carcinoma in her paternal grandfather and type 2 diabetes in her maternal grandmother. Six hours after her arrival at the tertiary hospital, and 12 hours from her first presentation and assessment at the local rural hospital, the patient began to decompensate with rapid progression of hypotension, tachycardia, and tachypnoea. The acute decompensation to hypotension and shock was assumed to be due to progression of the pancreatitis with potential infection complicating the pancreatitis. The patient was aggressively rehydrated and started on broad spectrum antibiotics. However, the hypotension failed to respond to fluid resuscitation and there was increased patient distress. She was urgently referred to the intensive care unit for supportive measures and management.

Aboulhosn K, Arnason T. Acute pancreatitis and severe hypertriglyceridaemia masking unsuspected underlying diabetic ketoacidosis. BMJ Case Rep 2013;2013, doi: 10.1136/bcr-2013-200431 .

Box 3: Learning points

Postpartum hellp syndrome and subcapsular liver haematoma.

Subcapsular liver haematoma is a potentially life threatening complication of severe pre-eclampsia and haemolysis, the breakdown of red blood cells; elevated liver enzymes; low platelet count syndrome.

The complication is rare but should be considered with severe upper abdominal pain in obstetric patients, especially in the presence of pre-eclampsia.

Real time ultrasound imaging of the liver is often diagnostic.

Messerschmidt L, Andersen LL, Sorensen MB. Postpartum HELLP syndrome and subcapsular liver haematoma. BMJ Case Rep 2014, doi: 10.1136/bcr-2013-202503 .

You should separate your case presentation section from the investigations and differential diagnoses. The key points to remember to include are your choice of investigations and how they helped you establish a working diagnosis (box 4).

Box 4: Investigations

Unilateral presentation of postpartum cardiomyopathy misdiagnosed as pneumonia.

On arriving at the emergency department, the patient had severe shortness of breath at rest 10 days after delivery. Her vital signs included an oral temperature of 36.7ºC, blood pressure 163/102 mmHg, pulse rate 146 beats/min, and oxygen saturation 88% in room air. Treatment with supplemental oxygen by mask yielded an increase in oxygen saturation to 95%. Her physical examination revealed no jugular venous distension, hepatic enlargement, or pedal oedema; heart sounds were fast and regular, with no evidence of murmurs or additional sounds. On lung auscultation bilateral crackles were present. Her laboratory analysis showed mild non-specific indicators of stress with a leucocyte count of 9.3×10 3 cells/mm 3 , haemoglobin value of 10.6 g/dL, and a platelet count of 791×10 3 cells/mm 3 . Her electrocardiogram was similar to the one obtained a day earlier showing T wave inversion in leads V4–V6; however, chest radiography showed a more bilateral presentation compared with the previous one showing both heart enlargement and pulmonary oedema. A chest computed tomography angiography performed to exclude pulmonary artery embolisation confirmed the presence of cardiomegaly and pulmonary oedema with bilateral effusions (fig 1). ⇓ An echocardiogram showed a diminished ejection fraction of 15-20% confirming the diagnosis of postpartum cardiomyopathy.

Amit BH, Marmor A, Hussein A. Unilateral presentation of postpartum cardiomyopathy misdiagnosed as pneumonia. BMJ Case Rep 2010, doi: 10.1136/bcr.05.2010.3039 .

Fig 1 Chest computed tomogram performed after deterioration showing heart enlargement, pulmonary oedema, and bilateral pleural effusions mainly on the right. From Amit BH et al. BMJ Case Rep 2010, doi: 10.1136/bcr.05.2010.3039 .

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Imagine that you are presenting at a grand round and have to explain your choices to your colleagues—this is essentially what you are doing as you write your case report. Do not simply list your differential diagnoses; describe how you worked through your list of differentials and how you established a final diagnosis.

Also, make sure you collect and include high quality and well annotated images that not only explain radiological findings but also show their importance in establishing your diagnosis.

Good quality annotated images

Fig 2 Craniocervical x ray film showing fusion of the posterior arch of C1 to the occiput. A fracture was not evident, but clinical suspicion prompted a computed tomography scan

Fig 3 Axial, left, and sagittal, right, computed tomography scans of the craniocervical junction at presentation showing fusion of the left occipital condyle with the lateral mass of C1 and a fracture involving both elements. The fracture is indicated by the arrowheads

Outcome and follow-up

The outcome and your follow-up of the patient are important. In both your case presentation and the section on patient outcome, you should describe what happened to your patient in terms of their specific symptoms, their general wellbeing, and their lifestyle and activity.

Some journals require you to write a summary of your case report. This usually has a word limit and appears in medical search engines, such as Pubmed/MEDLINE. It is the equivalent of the abstract of a research paper.

Ensure that your title is scientific and clinical. Cryptic and humorous titles translate poorly across a global audience and do not always accurately reflect the content of your case report. You may find that the word limit does not permit you to write all the detail you would want to include in the summary, but the background section allows you to do this. Try to make sure that the background section does not repeat the summary.

Publication process

Clinical videos and images are important alternatives or potential additions to clinical case reports which many journals encourage authors to submit. Again, prepare these in collaboration with clinical teachers or coauthors, who will help you annotate these images and point out important learning messages, and do this from the outset in the format of the journal that you have researched well and decided to submit your manuscript to.

All submitted case reports are usually sent for peer review. Reviewers are chosen according to their specialty and clinical or academic interests. Your choice of key words is therefore important as these are the basis for the assignment of reviewers. Keywords are also important for other authors doing literature searches who discover your case report and cite this in their own writing.

Decisions to accept, revise, or reject are based on editors’ and reviewers’ opinions together, and every attempt is made to ensure that criticism is constructive and useful.

Dependent on how quickly your manuscript is reviewed, you should receive a decision on your manuscript within three to six weeks of submission. Outright rejections for reasons such as the unsuitability of your manuscript for the particular journal and its audience, manuscripts in the wrong format, incomplete sections (especially the case presentation and differential diagnosis sections), and plagiarism tend to be prompt, and they would be easily avoided by following the steps above and choosing your patient, your topic, your journal, and your particular manuscript format well.

Rejections on the basis of the content of the case report tend to be at the peer review stage and may be a few weeks after submission. They could include reasons such as the lack of novelty or educational message, a poor literature search, or inconsistent clinical management. Again, this is avoidable by preparing well. It is unusual for a well thought out and well prepared manuscript to be rejected.

Autoformatting software, especially with references, may produce errors, so do double check these. Syntax errors, spelling mistakes, and poor grammar create a poor impression of an otherwise good case report. As always, first impressions matter, so be meticulous as you proofread your manuscript before you submit.

The entire process of publication depends on the number of revisions necessary and how quickly you submit a revised manuscript. For those of you aiming to submit in time to prepare for job applications, do take into account the time taken in the process of publication.

Further reading

1. BMJ Case Reports has produced a ‘‘How to’’ guide for completing case report submission: http://casereports.bmj.com/site/about/How_to_complete_full_cases_template.pdf .

2. BMJ Case Reports has produced a clinical case reports template which illustrates the important points in a manuscript and should help you in your writing: http://casereports.bmj.com/site/about/guidelines.xhtml .

3. Some journals recommend patient perspectives in the write up of a case report. An example is at http://casereports.bmj.com/content/2015/bcr-2014-208529.full?sid=bb53a333-2c59-453a-a9bf-5775edc0e5d7 .

Originally published as: Student BMJ 2016;24:h3731

Competing interests: SB and OJ are editors of BMJ Case Reports.

Provenance and peer review: Commissioned; not externally peer reviewed.

• ↵ Broca P. Remarks on the seat of the faculty of articulated language, following an observation of aphemia (loss of speech). Bulletin de la Société Anatomique . 1861 ; 6 : 330 -57. OpenUrl
• ↵ Jones HB. On a new substance occurring in the urine of a patient with mollities ossium. Philosophical Transactions of the Royal Society of London . 1848 ; 138 : 55 -62. OpenUrl CrossRef
• ↵ Parkinson J. An essay on the shaking palsy, 1817. J Neuropsych Clin Neurosci 2002 ; 14 : 223 -6. OpenUrl CrossRef PubMed Web of Science
• ↵ Gottlieb GJ, Ragaz A, Vogel JV, et al. A preliminary communication on extensively disseminated kaposige sarcoma in a young homosexual man. Am J Dermatopath 1981 ; 3 : 111 . OpenUrl CrossRef PubMed Web of Science

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How to Write a Medical Research Paper

Last Updated: February 5, 2024 Approved

This article was co-authored by Chris M. Matsko, MD . Dr. Chris M. Matsko is a retired physician based in Pittsburgh, Pennsylvania. With over 25 years of medical research experience, Dr. Matsko was awarded the Pittsburgh Cornell University Leadership Award for Excellence. He holds a BS in Nutritional Science from Cornell University and an MD from the Temple University School of Medicine in 2007. Dr. Matsko earned a Research Writing Certification from the American Medical Writers Association (AMWA) in 2016 and a Medical Writing & Editing Certification from the University of Chicago in 2017. wikiHow marks an article as reader-approved once it receives enough positive feedback. In this case, 89% of readers who voted found the article helpful, earning it our reader-approved status. This article has been viewed 201,905 times.

Writing a medical research paper is similar to writing other research papers in that you want to use reliable sources, write in a clear and organized style, and offer a strong argument for all conclusions you present. In some cases the research you discuss will be data you have actually collected to answer your research questions. Understanding proper formatting, citations, and style will help you write and informative and respected paper.

Researching Your Paper

• Pick something that really interests you to make the research more fun.
• Choose a topic that has unanswered questions and propose solutions.

• Quantitative studies consist of original research performed by the writer. These research papers will need to include sections like Hypothesis (or Research Question), Previous Findings, Method, Limitations, Results, Discussion, and Application.
• Synthesis papers review the research already published and analyze it. They find weaknesses and strengths in the research, apply it to a specific situation, and then indicate a direction for future research.

• Keep track of your sources. Write down all publication information necessary for citation: author, title of article, title of book or journal, publisher, edition, date published, volume number, issue number, page number, and anything else pertaining to your source. A program like Endnote can help you keep track of your sources.
• Take detailed notes as you read. Paraphrase information in your own words or if you copy directly from the article or book, indicate that these are direct quotes by using quotation marks to prevent plagiarism.
• Be sure to keep all of your notes with the correct source.
• Your professor and librarians can also help you find good resources.

• Keep all of your notes in a physical folder or in a digitized form on the computer.
• Start to form the basic outline of your paper using the notes you have collected.

Writing Your Paper

• Start with bullet points and then add in notes you've taken from references that support your ideas. [1] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source
• A common way to format research papers is to follow the IMRAD format. This dictates the structure of your paper in the following order: I ntroduction, M ethods, R esults, a nd D iscussion. [2] X Research source
• The outline is just the basic structure of your paper. Don't worry if you have to rearrange a few times to get it right.
• Ask others to look over your outline and get feedback on the organization.
• Know the audience you are writing for and adjust your style accordingly. [3] X Research source

• Use a standard font type and size, such as Times New Roman 12 point font.
• Double-space your paper.
• If necessary, create a cover page. Most schools require a cover page of some sort. Include your main title, running title (often a shortened version of your main title), author's name, course name, and semester.

• Break up information into sections and subsections and address one main point per section.
• Include any figures or data tables that support your main ideas.
• For a quantitative study, state the methods used to obtain results.

• Clearly state and summarize the main points of your research paper.
• Discuss how this research contributes to the field and why it is important. [4] X Research source
• Highlight potential applications of the theory if appropriate.
• Propose future directions that build upon the research you have presented. [5] X Research source
• Keep the introduction and discussion short, and spend more time explaining the methods and results.

• State why the problem is important to address.
• Discuss what is currently known and what is lacking in the field.
• State the objective of your paper.
• Keep the introduction short.

• Highlight the purpose of the paper and the main conclusions.
• State why your conclusions are important.
• Be concise in your summary of the paper.
• Show that you have a solid study design and a high-quality data set.
• Abstracts are usually one paragraph and between 250 – 500 words.

• Unless otherwise directed, use the American Medical Association (AMA) style guide to properly format citations.
• Add citations at end of a sentence to indicate that you are using someone else's idea. Use these throughout your research paper as needed. They include the author's last name, year of publication, and page number.
• Compile your reference list and add it to the end of your paper.
• Use a citation program if you have access to one to simplify the process.

• Continually revise your paper to make sure it is structured in a logical way.
• Proofread your paper for spelling and grammatical errors.
• Make sure you are following the proper formatting guidelines provided for the paper.
• Have others read your paper to proofread and check for clarity. Revise as needed.

Expert Q&A

• Ask your professor for help if you are stuck or confused about any part of your research paper. They are familiar with the style and structure of papers and can provide you with more resources. Thanks Helpful 0 Not Helpful 0
• Refer to your professor's specific guidelines. Some instructors modify parts of a research paper to better fit their assignment. Others may request supplementary details, such as a synopsis for your research project . Thanks Helpful 0 Not Helpful 0
• Set aside blocks of time specifically for writing each day. Thanks Helpful 0 Not Helpful 0

• Do not plagiarize. Plagiarism is using someone else's work, words, or ideas and presenting them as your own. It is important to cite all sources in your research paper, both through internal citations and on your reference page. Thanks Helpful 4 Not Helpful 2

You Might Also Like

• ↑ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178846/
• ↑ http://owl.excelsior.edu/research-and-citations/outlining/outlining-imrad/
• ↑ http://china.elsevier.com/ElsevierDNN/Portals/7/How%20to%20write%20a%20world-class%20paper.pdf
• ↑ http://intqhc.oxfordjournals.org/content/16/3/191
• ↑ http://www.ruf.rice.edu/~bioslabs/tools/report/reportform.html#form

About This Article

To write a medical research paper, research your topic thoroughly and compile your data. Next, organize your notes and create a strong outline that breaks up the information into sections and subsections, addressing one main point per section. Write the results and discussion sections first to go over your findings, then write the introduction to state your objective and provide background information. Finally, write the abstract, which concisely summarizes the article by highlighting the main points. For tips on formatting and using citations, read on! Did this summary help you? Yes No

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Writing a Case Report

This page is intended for medical students, residents or others who do not have much experience with case reports, but are planning on writing one.  

What is a case report?  A medical case report, also known as a case study, is a detailed description of a clinical encounter with a patient.  The most important aspect of a case report, i.e. the reason you would go to the trouble of writing one, is that the case is sufficiently unique, rare or interesting such that other medical professionals will learn something from it.   

Case reports are commonly of the following categories :

- Rare diseases

- Unusual presentation of disease

- Unexpected events

- Unusual combination of diseases or conditions

- Difficult or inconclusive diagnosis

- Treatment or management challenges

- Personal impact

- Observations that shed new light on a disease or condition

- Anatomical variations

It is important that you recognize what is unique or interesting about your case, and this must be described clearly in the case report.

Case reports generally take the format of :

1. Background

2. Case presentation

3. Observations and investigation

4. Diagnosis

5. Treatment

7. Discussion

Does a case report require IRB approval?

Case reports typically discuss a single patient. If this is true for your case report, then it most likely does not require IRB approval because it not considered research.    If you have more than one patient, your study could qualify as a Case Series, which would require IRB review.  If you have questions, you chould check your local IRB's guidelines on reviewing case reports.

Are there other rules for writing a case report?

First, you will be collecting protected health information, thus HIPAA applies to case reports.   Spectrum Health has created a very helpful guidance document for case reports, which you can see here:   Case Report Guidance - Spectrum Health

While this guidance document was created by Spectrum Health, the rules and regulations outlined could apply to any case report.  This includes answering questions like: Do I need written HIPAA authorization to publish a case report?  When do I need IRB review of a case report?  What qualifies as a patient identifier?

How do I get started?

1. We STRONGLY encourage you to consult the CARE Guidelines, which provide guidance on writing case reports -  https://www.care-statement.org/

Specifically, the checklist -  https://www.care-statement.org/checklist  - which explains exactly the information you should collect and include in your case report.  

2. Identify a case.  If you are a medical student, you may not yet have the clinical expertise to determine if a specific case is worth writing up.  If so, you must seek the help of a clinician.  It is common for students to ask attendings or residents if they have any interesting cases that can be used for a case report. 

3. Select a journal or two to which you think you will submit the case report.   Journals often have specific requirements for publishing case reports, which could include a requirement for informed consent, a letter or statement from the IRB and other things.  Journals may also charge publication fees (see Is it free to publish? below)   

4. Obtain informed consent from the patient (see " Do I have to obtain informed consent from the patient? " below).  Journals may have their own informed consent form that they would like you to use, so please look for this when selecting a journal.

Once you've identified the case, selected an appropriate journal(s), and considered informed consent, you can collect the required information to write the case report.

How do I write a case report?

Once you identify a case and have learned what information to include in the case report, try to find a previously published case report.  Finding published case reports in a similar field will provide examples to guide you through the process of writing a case report.    

One journal you can consult is BMJ Case Reports .  MSU has an institutional fellowship with BMJ Case Reports which allows MSU faculty, staff and students to publish in this journal for free.  See this page for a link to the journal and more information on publishing-    https://lib.msu.edu/medicalwriting_publishing/

There are numerous other journals where you can find published case reports to help guide you in your writing. 

Do I have to obtain informed consent from the patient?

The CARE guidelines recommend obtaining informed consent from patients for all case reports.  Our recommendation is to obtain informed consent from the patient.  Although not technically required, especially if the case report does not include any identifying information, some journals require informed consent for all case reports before publishing.  The CARE guidelines recommend obtaining informed consent AND the patient's perspective on the treatment/outcome (if possible).  Please consider this as well.  

If required, it is recommended you obtain informed consent before the case report is written.

An example of a case report consent form can be found on the BMJ Case Reports website, which you can access via the MSU library page -  https://casereports.bmj.com/ .  Go to "Instructions for Authors" and then "Patient Consent" to find the consent form they use.  You can create a similar form to obtain consent from your patient.  If you have identified a journal already, please consult their requirements and determine if they have a specific consent form they would like you to use.

Seek feedback

Once you have written a draft of the case report, you should seek feedback on your writing, from experts in the field if possible, or from those who have written case reports before.   

Selecting a journal

Aside from BMJ Case Reports mentioned above, there are many, many journals out there who publish medical case reports.   Ask your mentor if they have a journal they would like to use.  If you need to select on your own, here are some strategies:

1. Do a PubMed search.  https://pubmed.ncbi.nlm.nih.gov/

   a. Do a search for a topic, disease or other feature of your case report 

   b. When the results appear, on the left side of the page is a limiter for "article type".  Case reports are an article type to which you can limit your search results.  If you don't see that option on the left, click "additional filters". 

   c. Review the case reports that come up and see what journals they are published in.

2. Use JANE -  https://jane.biosemantics.org/

3. Check with specialty societies.  Many specialty societies are affiliated with one or more journal, which can be reviewed for ones that match your needs

4. Search through individual publisher journal lists.  Elsevier publishes many different medical research journals, and they have a journal finder, much like JANE  ( https://journalfinder.elsevier.com/ ).  This is exclusive to Elsevier journals.  There are many other publishers of medical journals for review, including Springer, Dove Press, BMJ, BMC, Wiley, Sage, Nature and many others.

Is it free to publish ?

Be aware that it may not be free to publish your case report.  Many journals charge publication fees. Of note, many open access journals charge author fees of thousands of dollars.  Other journals have smaller page charges (i.e. $60 per page), and still others will publish for free, with an "open access option".  It is best practice to check the journal's Info for Authors section or Author Center to determine what the cost is to publish.  MSU-CHM does NOT have funds to support publication costs, so this is an important step if you do not want to pay out of pocket for publishing

*A more thorough discussion on finding a journal, publication costs, predatory journals and other publication-related issues can be found here:   https://research.chm.msu.edu/students-residents/finding-a-journal

Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D. 2013. The CARE guidelines: Consensus-based clinical case reporting guideline development.  Glob Adv Health Med . 2:38-43. doi:  10.7453/gahmj.2013.008

Riley DS, Barber MS, Kienle GS, AronsonJK, von Schoen-Angerer T, Tugwell P, Kiene H, Helfand M, Altman DG, Sox H, Werthmann PG, Moher D, Rison RA, Shamseer L, Koch CA, Sun GH, Hanaway P, Sudak NL, Kaszkin-Bettag M, Carpenter JE, Gagnier JJ. 2017.  CARE guidelines for case reports: explanation and elaboration document . J Clin Epidemiol . 89:218-234. doi: 10.1016/j.jclinepi.2017.04.026 

Guidelines to writing a clinical case report. 2017. Heart Views . 18:104-105. doi:  10.4103/1995-705X.217857

Ortega-Loubon C, Culquichicon C, Correa R. The importance of writing and publishing case reports during medical education. 2017. Cureus. 9:e1964. doi:  10.7759/cureus.1964

Writing and publishing a useful and interesting case report. 2019. BMJ Case Reports.  https://casereports.bmj.com/pages/wp-content/uploads/sites/69/2019/04/How-to-write-a-Case-Report-DIGITAL.pdf

Camm CF. Writing an excellent case report: EHJ Case Reports , Case of the Year 2019. 2020. European Heart Jounrnal. 41:1230-1231.  https://doi.org/10.1093/eurheartj/ehaa176  

*content developed by Mark Trottier, PhD

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Top 7 Medical Report Templates with Examples and Samples

Samradni Pradhan

Ever thought about dictates the functioning of your healthcare enterprise and how are you able to run very complex business? That's where medical reports come in and help you identify the vital signs of your operations. Before that, of course, it will pay you to know that 80% of successful healthcare strategies are rooted in insightful medical reporting. Now, imagine having a tool that transforms these reports from a data labyrinth into a clear roadmap.

Enter SlideTeam’s Medical Report Templates, designed to demystify your healthcare narrative. In a world where 90% of healthcare executives believe effective data use is paramount, these 100% editable and customizable templates become your beacon. You get structure, a starting point and the capability to customize each template to audience profile.

These are not just templates; these the storytellers of your medical journey, unravelling the complexities of patient care, operational efficiency, and strategic growth.

Understand and create a world where data meets clarity, curiosity sparks transformation, and your medical reports become the catalysts for a healthier, more informed future.

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Template 1: Medical company CEO message template

Introducing a concise and impactful tool for your CEO to convey the vision and achievements of your healthcare enterprise. Crafted with eloquence, it provides a structured framework for expressing gratitude, highlighting accomplishments, and outlining future aspirations. Whether acknowledging team dedication, unveiling medical breakthroughs, or casting a forward-looking vision, this template empowers your leadership to communicate well. Download now for a message that inspires confidence and trust, allowing your CEO's voice to resonate with impact and purpose.

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Showcase the legacy of your pharmaceutical enterprise with our template. This document encapsulates the evolution, milestones, and pioneering contributions that shape your company's narrative. From groundbreaking research to transformative healthcare solutions, this template traces the historical journey of your pharmaceutical endeavors. Engage stakeholders with timelines, dynamic infographics, and anecdotes that highlight the unique chapters in your company's history. This template ensures a personalized storytelling experience, allowing your pharmaceutical legacy to be communicated with clarity and resonance. Download now and depict the rich tapestry of your company's history.

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Unveil the triumphs of your medical enterprise with our PPT Template that document goes beyond mere statistics. Use this presentation to intricately detail the transformative milestones and breakthroughs that define your company's success story. From cutting-edge innovations to impactful community initiatives, this layout celebrates your achievements. Incorporate captivating visuals, personalized narratives, and dynamic infographics to vividly showcase the journey of excellence. Easily customizable, this template offers a tailored canvas to highlight awards, industry recognition, and the human impact of your medical innovations. Enhance your narrative and share the heart of your accomplishments with stakeholders, investors, and the wider healthcare community.

Template 4: Medical company business review template

Introducing an exceptional tool that transforms data into a compelling narrative. This PPT Template offers a dynamic overview of financial performance, strategic initiatives, and key milestones. Navigate through charts, personalized sections, and visually engaging infographics to communicate the distinctive strengths of your medical enterprise. Tailor this template to showcase your business's unique identity, from innovative healthcare solutions to strategic partnerships. Illuminate the path to success by downloading this template right away!

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Introducing a transformative framework to showcase your company's commitment to positive impact. This innovative template goes beyond numbers, enabling you to illustrate human stories that drive your CSR initiatives. From community outreach to environmental stewardship, integrate impactful visuals and narratives, creating a compelling CSR narrative. Tailor this template to reflect your company's unique ethos, emphasizing the genuine connections forged through socially responsible endeavours. Ideal for stakeholder presentations and reports, it ensures your CSR efforts resonate authentically. Download now to articulate your company's social conscience with our CSR Template — where purpose meets presentation.

Template 6: Key risks and status of response PPT Template

Identify proactive risk management with our PPT Template. This dynamic document goes beyond traditional risk assessments, offering a comprehensive view of potential challenges and the status of strategic responses. Navigate through charts and succinct summaries to grasp the intricate web of risks and the effectiveness of mitigation strategies. This template is your compass for informed decision-making, ensuring a real-time understanding of your business landscape. It includes information on the matters assessed, specific anticipated risks and the state of response. Tailor it to reflect your company's unique risk profile, empowering stakeholders with a clear, actionable view. Download now and fortify your strategy with our presentation template — where insight meets resilience.

Template 7: Consolidated statement of financial position PPT Template

Here’s a tool that transcends conventional financial reporting. This PPT Template transforms numbers into a visual symphony, providing stakeholders with an immersive, intuitive understanding of your company's fiscal health. Dive into dynamic charts and insightful breakdowns that redefine how financial data is presented. Tailor this template to encapsulate the unique financial story of your enterprise, emphasizing strategic allocations and growth trajectories. Users will find this template to be a perfect fit for executive briefings and investor meetings. The end-goal is to ensure your financial narrative stands out with clarity and sophistication. Download now to redefine financial reporting.

Template 8: One-pager medical company annual report summary presentation report 

Introducing an unparalleled tool that highlights a year’s worth of achievements into a single, wonderfully-designed, hands-on action page. This PPT Template blends aesthetics with functionality, allowing you to encapsulate highlights, financial insights, and strategic vision in a concise yet impactful manner. Showcase your medical company's growth, financial milestones, and outlook with precision through this design and template. Highlight key metrics, significant accomplishments, and strategic initiatives with customizable elements, ensuring a tailored representation of your unique journey. This one-pager is designed for maximum engagement, offering a dynamic snapshot that captivates stakeholders and investors alike. Whether it's detailing breakthroughs in healthcare innovation, showcasing financial prowess, or outlining strategic pathways, this layout provides you a near-perfect annual report summary. Create an engaging medical company narrative with this template with a download right away!

Template 9: One-page review and statistics for medical app presentation report 

Meant for mobile health applications, this one-page review template allows you to showcase key app statistics. Easily customize sections for app name, category, owner, and other pertinent details, even incorporating your company's logo for a personalized touch. Highlight your app's success with a visually appealing bar graph that compares user growth between the previous and current year, offering a clear overview of your app's performance. This presentation template enables you to conduct a comparative analysis against competitors, emphasizing awards and positive customer reviews. Tailor the elements to suit your unique requirements, ensuring a captivating presentation of your medical app’s achievements. Upgrade your app evaluation with our template — your gateway to impressively communicate data and captivate your audience. Don't miss out — download this essential tool for effective medical app presentations now.

PAINT A HEALTHY PICTURE OF THE FUTURE

These templates redefine the landscape of healthcare documentation. From patient care summaries to operational analyses, each template serves as a powerful ally in navigating the complexities of the medical realm. By combining clarity, customization, and innovation, these templates empower healthcare professionals to communicate insights. Now, armed with diverse examples and samples, you have the tools to elevate your medical reporting game. It's not just about data; it's about the impactful stories these reports tell. Embrace efficiency, enhance communication, and chart a course towards a healthier, more informed future with these exceptional medical report templates.

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Guideline on writing a case report

Basim saleh alsaywid.

1 Department of Surgery, King Abdulaziz Medical City, Ministry of National Guard, Jeddah, Saudi Arabia

2 Department of Research Unit, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia

Nada Mansour Abdulhaq

3 Department of Pediatric, Rabigh Branch, King Abdulaziz University, Jeddah, Saudi Arabia

4 Department of Medicine, King Abdulaziz Medical City, Jeddah, Saudi Arabia

Research is an important competency that should be mastered by medical professionals. It provides an opportunity for physicians to develop numerous skills including communication, collaboration, time management, and teamwork. Case report, as a research design, describes important scientific observations that are encountered in a clinical setting to expand our knowledge base. Preparing a case report is far easier than conducting any other elaborative research design. Case report, with its main components, should be focused and delivers a clear message. In this article, the key components of a case report were described with the aim of providing guidance to novice authors to improve the quality of their reporting.

INTRODUCTION

“The best teaching of medicine is that taught by the patient himself” is a famous statement by William Osler which describes the opportunities we have as physicians to learn from our encounters with patients.[ 1 ] This learning experience, based on the observation of clinical cases, can be transferred to others, locally, nationally, and internationally, through communication and reporting. A case report is the first effort for many doctors, and other health professionals to convey a message to the entire medical profession by the means of specialized journal and remain essential to the art of medicine.[ 2 ] The purpose of the case report is to expand our knowledge on clinical manifestation, diagnostic approach, or therapeutic alternative of a disease, ultimately, to improve the quality of care provided to our patients. A case report that is worth reading should, therefore, contain both practical and educational messages.[ 3 , 4 ]

The clinical case report has been an integral part of medical literature throughout history. The oldest example of a preserved clinical case in medical literature is a text from an ancient Egyptian papyrus dating from the 16 th to the 17 th dynasty, 1600 BC, addressing the management of dislocated jawbone.[ 5 ] From Hippocratic case histories, “Epidemics” 400 BC, through Galenic case reports, in the second century AD, case reports were usually used to tell other doctors or colleagues about interesting cases they have encountered. Muslim scholars have reported case histories as well, particularly, Abu Bakr Mohamed Ibn Zakariya Al-Razi (865–929 AD), where he left a large collection of case reports in his 25-volume medical encyclopedia “Kitab Al-Hawi.”[ 5 ]

Those case histories were not a publication but rather a documentation or a message between the medical professionals, and it is usually kept in their records. Case reports have now been developed and accepted as a scholarly publication to disseminate knowledge to a wide medical audience.

GENERAL PRINCIPLES OF CASES REPORT

The case report is a research design where an unexpected or novel occurrence is described in a detailed report of findings, clinical course, and prognosis of an individual patient, which might be, but not mandatory, accompanied by a review of the literature of other reported cases. Although case reports are considered the lowest in the hierarchy of evidence-based practice in the medical literature [ Figure 1 ], it provides essential information for unfamiliar events and shared individual experiences, for better understanding and optimizing patient care. This approach might generate an idea or hypothesis, but it will not be confirmed unless we conduct further confirmatory quantitative experimental or observational study designs such as clinical trials or cohort studies. Despite that, case report provides the medical community with information which cannot be picked up by any other designs. Just to name a few, in 1819, James Parkinson published a case report entitled “An essay on the shaking palsy”[ 6 ] and lead to the discovery of Parkinson's disease. And in 1981, a case report was published in the literature as “Preliminary communication on extensively disseminated Kaposi sarcoma in a young homosexual man”[ 7 ] few years later, HIV from this case report was discovered. Furthermore, in 2012, Ali Zaki reported an article in New England Journal of Medicine titled “Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia” which ultimately, lead to the discovery of Middle East Respiratory Syndrome Coronavirus.[ 8 ] All those previous examples show how important is case report in the advancement of medical practice. The case report might be in the tail of the hierarchy of evidence-based medicine but if properly selected and appropriately reported it might stand a better chance of publication in high impact journals than even a clinical trial.

Hierarchy of evidence base medicine

Some scientist classifies case reports as a qualitative study design, others might consider it a quantitative approach or even a mixed method design.[ 9 ] This polarization of the case report is unfair. However, if we have to categorize it; when we consider all research approaches in medicine, it can be classified into exploratory or confirmatory; then, case reports definitely will be considered an exploratory research approach. Case report can be classified as a single case report, two case reports or case series, which aggregate more than two cases in a report. Case reports are usually retrospective by nature, however, it can be prospectively designed, for example, applying a new diagnostic or management approach or guideline of a particular health condition to discover new cases.[ 10 ]

Cases deemed appropriate for a publication are listed in Table 1 .[ 3 ] Despite these restrictive criteria, any case report could have a reasonable chance of publication even if it was not novel, as long as it was authentic, lead to an incremental advance in medicine or carries an educational value.

Criteria for published case report

STAGES IN PREPARING A CASE REPORT

The source of case reports is clinical setting, every single patient is a potential case report therefore, always keep an eye on unusual cases in your practice either in the ward or in the clinic. Once a potential case is identified, and the patient is in hospital, follow him through hospitalization until discharge. Give the case an appropriate time frame in the course of the disease to observe the development over time. Wait for 6 months during multiple visits, before you start writing a case report to allow adequate time to complete the clinical course.

Once you have a potential case, how would you know if this is an appropriate for reporting or not? Especially if you are a novice physician, once you encounter a possible case and you are suspecting if this patient fulfills one of those criteria which are described in Table 1 . The first step is a high index of suspicion; keep your eyes open for every case, once you suspect a case then ask your colleagues either directly or in a group related to the same discipline, locally, to confirm that this could be a case report. The next step would be asking an expert from the national or international medical community about this case scenario, get their opinion and feedback, including the appropriateness of reporting this case. Once the feedback is positive, perform extensive literature search, through PubMed, Embase, Google Scholar, and databases for case reports to ensure that you retrieve all available information on this topic. Do not forget to look at popular case reports which are not indexed in PubMed and read through previously published case reports that will enhance your understanding of the subject and gives you a general scaffold to prepare your own report.

Once the decision was made to report this case, obtain an informed consent from the patient; otherwise, it will not be accepted for publication. Moreover, take a permission from consultant in-charge of the case before writing your report.

Once you have reviewed the literature and improved your knowledge on the topic, use the patient's note to record the key points in history, examination findings, relevant data results and interpretation, treatment (including operational findings), and outcomes. Delete all patients’ personal information, identifiers or contact detailed from the prepared report, including the radiological or histopathological images before you copy them into your article. Save the prepared report on a password protected hospital computer.

The last step would be checking the journal which is most appropriate for your case report. Those journals provide you with the required criteria and appropriate format to prepare your report, to enhance their acceptability for publication. Many journals are interested in published case reports, but not all. In 2007, the first case report journal was created “Journal of Medical Case Reports” since then, the interest raised and many other journals dedicated for case reports were created including a specific database for all case reports are aggregated and continuously updated from several publishers.[ 3 ]

FORMAT FOR WRITING A CASE REPORTS

The word count for case report may vary from one journal to another, but generally should not exceed 1500 words, therefore, your final version of the report should be clear, concise, and focused, including only relevant information with enough details.[ 3 ] If a shorter version is required by the journal, then you can always edit or trim off the discussion section of your article. The general format adopted for most case reports is detailed in the following subsection and summarized as a checklist in Table 2 .

Checklist for writing a case report

This is the most commonly read part of your article; therefore, it should be relevant, concise, informative, descriptive, and appealing enough to attract readers to your report. It is placed in the first page of the manuscript, but some journal might request you to specify a separate file from the manuscript, labeled as a “title page” file. In preparing the title, avoid unnecessary words, wordplay, double meaning, cute wording, and never uses abbreviations in the title. It is always advisable to add “case report” in your title. Beneath the title, list all authors and their affiliations on the same page including their E-mails account. Most of the case reports are not prepared by a single author, but it should not exceed more than six authors; otherwise, the journal might not accept your case report for publication. Finally, under the subsection of corresponding author, assign one author to communicate with the journal and include all details of communication, such as institutional address, E-mail, and phone numbers.

Who should be the corresponding author? Any person who will submit the article to the journal to get the feedback from the editor of the journal and should be one of the article's authors.

It is the most important part of your article as it will be freely accessible for others to read when retrieved from any medical databases during the relevant search. However, it is the last part written in your article. It should include a brief summary that gives a general idea of the content of the case report. It should not include any references or abbreviations and should not exceed 350 words, preferably <250 words. Check your journal instructions for a detailed guideline on word counts. The abstract is usually arranged into three subsections: background, case presentation, and conclusion. The background should clarify the importance of reporting such a unique case. Afterward, a brief description of the clinical scenario of the patient listing only the important details. Finally, the conclusion should be brief with lesson learned and impact on the interested group.

This is quite important for indexing your article, and it should be from three to ten words, and you should be very careful in your selection, as it would help in retrieving your paper during the search.

Introduction

In this section, the definition and brief description of the pathology, including common presentations and disease progression is discussed, explaining the background of the selected topic. Followed by a brief description of what is about to be reported and the importance of reporting such case. The content should be clear, focused, concise, and attract the reader's attention and interest.

Case presentation

Provide a clear picture of the patient's condition and presentation, and it is best presented in chronological order with sufficient detail and explanation. Describe the relevant demographic information of the patient censoring any details that could lead to the patient being identified. Start with the current medical condition and primary complaint with detailed history including relevant family history, occupational and social history, medication, and allergy. Findings of physical examination should be briefly reported with all relevant investigation, laboratory results and images, and its analysis. Describe the differential diagnosis and the rational of the management approach, including follow-up results and final diagnosis. Avoid any extensive interpretation or defense for the approach you took. This section can be broken up into small subsections if needed, and it should be supplemented with necessary images and tables to facilitate reader's understanding of the case.

Probably, this is an optional section, but it is preferable if reported, as it would explain more of your rational and approach with added additional relevant information about the uniqueness of this case. Compare your findings with what is known in the literature and why you think this case is different. Only discuss what is relevant to your case and do not provide any unproven and unsupported speculation. Acknowledge and explain any ambiguity or unexpected features occurred even if it is contradicting your concept. Explain how this case would contribute to the literature and suggest justifiable recommendations.

The section should include a concise and brief statement, explaining the importance and relevance of your case and it should relate to the purpose of the paper.

Patient's perspective

This new section is an optional, but it adds a new dimension to your paper, as it gives the chance to patients with their own perspective to write and describe their experiences throughout the disease process. Make sure that any patient's identifiers are removed, and his identity is managed appropriately with confidentiality, removing all irrelevant information to the case report.

Before submission, make sure that the patient gave his informed consent for publication, and statement indicating that should be clearly narrated in the report. You do not need to send the consent form on submission, but it should be available if requested. In case of the child, the parent or legal guardian should be consented instead, and if the child is a teenager then both patient and his parent should be consented. Many journals will not proceed with the peer review process unless a statement like “written informed consent was obtained from the patient for publication” is clearly stated. This statement could be in a separate section, as indicated here, or within the content of the report. If the patient is incapacitated or deceased, obtain the consent from the next-of-kin, and this should be stated clearly in the report. If the patient is deceased and next-of-kin is unreachable, you should exhaust all reasonable attempts to obtain the consent. If you fail, then you should state that in your report. If the patient is still alive but unreachable and you did not obtain the consent, do not bother publishing the case.[ 3 ]

Competing of interest

In this mandatory part, all authors should disclose any financial competing interest. If none, then, a statement like “the authors declare that they have no competing interests” should be clearly stated.

Author contribution

In this section, you need to credit all individuals who made a substantial contribution to the production of this study. Criteria of qualification to be an author should be strictly followed and explicitly stated for each author, separately. The first criterion is being a part of the conceptual development, data acquisition or analysis, then involvement in drafting part of the manuscript, and finally approving the final version of the manuscript. If those criteria are not fulfilled, then those individuals should be acknowledged in the next section. Be cautious from excessive authorship as this might lead to rejecting your article.

You need to mention around 15 references if possible, and few of them should be within the past 5 years, but do not exceed more than 25 references.

Cover letter

This is an optional supplementary document, addressed to the editor-in-chief, in a formal letter. Explain why this report is important and why it should be published in this journal.

JOURNAL EVALUATION FOR A CASE REPORT

Writing a case report varies from one physician to another, depending on the expertise of the author who prepared the report. This variation is influenced by many factors ranging from the author's knowledge base to his writing skills. The Peer review process will detect this variation to assure the quality of reporting through critical appraisal. It will assess the report, provide a valuable, supposedly constructive, feedback and helps the editor in a decision regarding the publication. This assessment should be as objective as possible to reach an unbiased decision. Therefore, several schemes were formulated to evaluate the quality of the case report. One of which is the Piersons 5-component scheme which relays on five major components, each component is scored from 0 to two, with a possible total score of 10 and lowest score of zero. The five major components are uniqueness, documentation, interpretation, objectivity, and educational value.[ 11 ] If the calculated score is more than 8, then this report is worth publishing. A score from 6 to 8, indicate possible publication with caution about validity. Any score <6, indicate the insufficient quality of the case report. Further details about this evaluation scheme are explained in Table 3 .

Matrix of case report evaluation

The calculated total score: Score of 9-10: Excellent report and most likely will add new information to the medical literature, Score of 6-8: Can be published but reader should be caution of validity and clinical value, Score of 5 or Less: Report is considered inadequate and inappropriate for publication

Case report remains an important source of information and common method in knowledge dissemination among physicians due to its simplicity in design. It will continue providing new research ideas through hypotheses generation. Finally, as I commenced my article with William Osler, I will end by quoting his other famous statement…. “Always note and record the unusual…. Publish it, place it on permanent record as a short, concise note. Such communication is always of value.”

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Acknowledgment

You need to mention and acknowledge the source of the research fund if any. Moreover, acknowledging all people who helped you, supervised you, or assisted you in finalizing this report, if they are not fulfilling the criteria to be an author.

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How to Write a Medical Abstract for Publication

Preparing Your Study, Review, or Article for Publication in Medical Journals

The majority of social, behavioral, biological, and clinical journals follow the conventional structured abstract form with the following four major headings (or variations of these headings):

OBJECTIVE   (Purpose; Aim; Goal) : Tells reader the purpose of your research and the questions it intends to answer

METHODS   (Setting; Study Design; Participants) : Explains the methods and process so that other researchers can assess, review, and replicate your study.

RESULTS (Findings; Outcomes) : Summarizes the most important findings of your study

CONCLUSIONS   (Discussion; Implications; Further Recommendations) : Summarizes the interpretation and implications of these results and presents recommendations for further research

Sample Health/Medical Abstract

Structured Abstracts Guidelines *

• Total Word Count: ~200-300 words (depending on the journal)
• Content: The abstract should reflect only the contents of the original paper (no cited work)

*   Always follow the formatting guidelines of the journal to which you are submitting your paper.

Useful Terms and Phrases by Abstract Section

Objective:  state your precise research purpose or question (1-2 sentences).

• Begin with “To”: “We aimed to…” or “The objective of this study was to…” using a verb that accurately captures the action of your study.
• Connect the verb to an object phrase to capture the central elements and purpose of the study, hypothesis , or research problem . Include details about the setting, demographics, and the problem or intervention you are investigating.

METHODS : Explain the tools and steps of your research (1-3 sentences)

• Use the past tense if the study has been conducted; use the present tense if the study is in progress.
• Include details about the study design, sample groups and sizes, variables, procedures, outcome measures, controls, and methods of analysis.

  RESULTS : Summarize the data you obtained (3-6 sentences)

• Use the past tense when describing the actions or outcomes of the research.
• Include results that answer the research question and that were derived from the stated methods; examine data by qualitative or quantitative means.
• State whether the research question or hypothesis was proven or disproven.

CONCLUSIONS : Describe the key findings (2-5 sentences)

• Use the present tense to discuss the findings and implications of the study results.
• Explain the implications of these results for medicine, science, or society.
• Discuss any major limitations of the study and suggest further actions or research that should be undertaken.

Before submitting your abstract to medical journals, be sure to receive proofreading services from Wordvice, including journal manuscript editing and paper proofreading , to enhance your writing impact and fix any remaining errors.

Related Resources

• 40 Useful Words and Phrases for Top-Notch Essays  (Oxford Royale Academy)
• 100+ Strong Verbs That Will Make Your Research Writing Amazing  (Wordvice)
• Essential Academic Writing Words and Phrases  (My English Teacher.eu)
• Academic Vocabulary, Useful Phrases for Academic Writing and Research Paper Writing  (Research Gate)
• How to Compose a Journal Submission Cover Letter  (Wordvice/YouTube)
• How to Write the Best Journal Submission Cover Letter  (Wordvice)

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Medical research articles from across Nature Portfolio

Medical research involves research in a wide range of fields, such as biology, chemistry, pharmacology and toxicology with the goal of developing new medicines or medical procedures or improving the application of those already available. It can be viewed as encompassing preclinical research (for example, in cellular systems and animal models) and clinical research (for example, clinical trials).

Functional precision medicine for pediatric cancers

A small, prospective clinical study shows that ex vivo drug screening of pediatric cancer samples can identify effective therapeutic options. If validated, these findings could herald a new approach to precision medicine in this setting.

• M. Emmy M. Dolman
• Paul G. Ekert

Blocking cell death limits lung damage and inflammation from influenza

Animals that receive an inhibitor of an antiviral cell-death response called necroptosis are less likely to die of influenza even at a late stage of infection. This has implications for the development of therapies for respiratory diseases.

• Nishma Gupta

Frequent jumps from human hosts

An analysis of publicly available viral genomes explores the evolutionary dynamics of host jumps and shows that humans are as much a source of viral spillover events to other animals as they are recipients.

• Christophe Dessimoz

Related Subjects

• Drug development
• Epidemiology
• Experimental models of disease
• Genetics research
• Outcomes research
• Paediatric research
• Preclinical research
• Stem-cell research
• Clinical trial design
• Translational research

Latest Research and Reviews

Open access EEG dataset of repeated measurements from a single subject for microstate analysis

• Shuyong Jia
• Guangjun Wang

Combination therapies with ponatinib and asciminib in a preclinical model of chronic myeloid leukemia blast crisis with compound mutations

• Nikola Curik
• Adam Laznicka
• Katerina Machova Polakova

Prediction of hematologic toxicity in luminal type breast cancer patients receiving neoadjuvant chemotherapy using CT L1 level skeletal muscle index

• Pinxiu Wang
• Wenzhen Yuan

Multi-center study on mortality in children, and adults with sickle cell anemia-risk factors and causes of death

• Salam Alkindi
• Salma Al-Jadidi
• Anil V. Pathare

Visceral-to-peripheral adiposity ratio: a critical determinant of sex and ethnic differences in cardiovascular risks among Asian Indians and African Creoles in Mauritius

• Vinaysing Ramessur
• Sadhna Hunma
• Abdul G. Dulloo

Non-preventable cases of breast, prostate, lung, and colorectal cancer in 2050 in an elimination scenario of modifiable risk factors

• Frederik Knude Palshof
• Lina Steinrud Mørch
• Niels Kroman

News and Comment

Busulfan plus cyclophosphamide vs. total body irradiation plus cyclophosphamide for allogeneic hematopoietic stem cell transplantation in patients with acute T lymphoblastic leukemia: a large-scale propensity score matching-based study

• Minyuan Liu

Safety and efficacy of a new academic CD19-directed CAR-T cell for refractory/relapsed non-Hodgkin lymphoma and acute lymphoblastic leukemia in Brazil

• Camila D. Donadel
• Gil C. De Santis
• Diego V. Clé

CD56 expression predicts response to Daratumumab-based regimens

• Allen J. Robinette
• Laila Huric
• Francesca Cottini

Efficacy of eculizumab in transplantation-associated thrombotic microangiopathy: results of the French nationwide study on behalf of the SFGM-TC and the CNR-MAT

• Marion Peyre
• Flore Sicre de Fontbrune

Why diversity is needed at every level of clinical trials, from participants to leaders

Diversity in clinical trials must be accompanied by justice and equity, including benefits for underrepresented participants, in order to boost population health.

• Khadijah Breathett

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Medical Report

Remember that all kinds of organizations make use of reports. Hospitals and other medical institutions are no exceptions. Rather than deal with things like sales reports and the like, those organizations are responsible for creating a medical report. Are you curious enough to try and learn more? No problem. Scroll on and we’ll not only provide information that’s about medical reports, but you’ll also come across examples of what an excellent medical report template looks like.

Medical Report Template

• Google Docs

Size: 209 KB

Medical Annual Report Tri-Fold Brochure Template

• Apple Pages
• Illustrator
• MS Publisher

Size: 102 KB

Medical Annual Report Bi-Fold Brochure Template

Size: 94 KB

Customer Medical Report

Medical Condition Report

Size: 661 kB

Medical Examination Report

Size: 827 kB

Children Medical Report

Size: 11 kB

Printable Medical Report

Size: 178 kB

Medical Record Report

Size: 45 kB

Student Medical Report

Size: 206 kB

Medical Summary Report

Size: 345 kB

What Is a Medical Report?

From the name itself, a medical report is a written report that usually contains the results of a medical examination conducted on a patient. It describes or outlines the findings of a medical professional, along with any suggestions for the patient’s treatment and recovery. Also referred to as a medical report letter, there’s lots more to learn about this, including how to write a medical report letter, which we will be tackling shortly.

Tips for Creating a Medical Report from Scratch

Moving on, we will now discuss the varied creation process of medical reports. Those eager to learn how to write a medical report will also be happy to know that there’s no need for strict steps or adhering to any formal medical report form. To create a medical report, all one has to do is follow the following steps:

Tip 1: Make it Comprehensive

A medical report that comes off as vague is practically useless. For it to be valid and useful, the medical  professional writing it must go into detail. With that said, use specific terms and provide particular comments and suggestions for the benefit of the report’s recipient.

Tip 2: Provide a Chronological Timeline

Sometimes, it is necessary to draw up a timeline of the patient’s symptoms. Doing so will help guide other professionals who may be assisting the patient with his or her treatment. When writing up a timeline, stick to chronological order and make it as easy to understand as possible.

Tip 3: Avoid Too Much Jargon

Since a medical report is meant for the benefit of the patient, it pays not to utilize too much vague medical jargon . Use professional language and ensure that there is enough clarity to prevent any misunderstandings among all of the involved parties.

Tip 4: Keep a Personal Copy

The creation of a medical report may dictate that you keep a separate but identical copy for yourself. The purpose of doing so is purely related to documentation . Also, in the event that the original medical report is somehow lost or tampered with, the patient can always turn back to you for references.

What are common inclusions in a medical report?

Besides the patient’s personal data, there are also multiple kinds of information written into these reports. Among the numerous inclusions would be: possible allergies, vaccinations, current medical evaluation , health issues, family or personal medical history, and more.

What are the different kinds of medical reports?

For some of the more in-depth and extensive examples, the different kinds of medical reports often include radiology reports, printable laboratory reports , and pathology reports.

How does a medical report differ from a prescription?

A medical report tends to be all-encompassing, complete with details of a patient’s illness and even prescriptions. If you’re just talking about prescriptions as a stand-alone document, then the details are much sparser, with only the doctor’s prescribed treatments and some of the patient’s personal  details written on it.

Considering how complicated a  hospital’s daily operations can be, there was already an idea of how nuanced medical reports are. With that said, there’s just as many kinds of information out there that you may not have realized before. It is our hope that we were able to cover as much of it, such as the tidbits about how to write a medical report for a patient. Having reached the end of this article, we implore you to choose carefully regarding how you will use your new-found knowledge. Decide with wisdom and act as soon as you can!

Report Generator

Text prompt

• Instructive
• Professional

Generate a report on the impact of technology in the classroom on student learning outcomes

Prepare a report analyzing the trends in student participation in sports and arts programs over the last five years at your school.

Medical Research: Forms & Consent Templates

Main navigation.

This section contains all of the forms and consent templates that apply to investigators from:     • School of Medicine (SoM)    • Veteran's Affairs (VA) Hospital 

*Please note that when creating a protocol for IRB submission, these investigators need to select the Medical eProtocol Application category.

If you have questions or are having trouble accessing these forms, please contact IRB Education ( email or call 650-724-7141).

The consent/assent form should be in a language that is understandable to someone without a medical or scientific background. Please use the Microsoft Readability Statistics tool as needed when writing your consent form.

See  consent template updates  for recent changes.

Other Forms:

Eprotocol forms:.