CARE Checklist: Writing a Publishable Case Report

The CARE checklist is a 13-item reporting guideline for case reports, published by Gagnier and colleagues in 2013. The name is formed from CAse REport. It specifies what the write-up of a single patient's clinical episode must contain for it to be usable by another clinician, and two of its items are unusual among reporting guidelines: a timeline of the episode, and the patient's own perspective on their experience.

Case reports occupy a peculiar position in research. They are the most accessible form of publication, often a clinician's first, and simultaneously the form most likely to be rejected, usually for a reason that has nothing to do with writing quality. The commonest fatal problem is that the case has no takeaway. A report that describes an unusual event and stops has documented something without teaching anything, and rarity by itself is not a contribution.

What makes a case worth reporting

Before the checklist, the judgement. A case earns publication when it changes something a reader might do. In practice that means one of a small number of things:

• An unexpected presentation of a common condition, such that a clinician might otherwise miss it.
• An adverse or unexpected effect of a drug, device or procedure, particularly one not in the existing literature.
• A diagnostic pitfall, where the obvious interpretation of findings was wrong and there was a way to tell.
• A management approach that worked where standard treatment had failed, or a novel application of an existing treatment.
• A genuinely rare condition described in enough detail to help with recognition, which is the weakest of the five and needs the most careful framing.

If your case does not fit one of these, the honest options are to write it up as an educational piece rather than a research report, or to combine it with similar cases into a case series, which supports a slightly stronger claim. Our healthcare case study service handles both routes.

The 13 items

Described in our own words. The authoritative wording and the checklist file sit with the guideline and are indexed on the guideline library EQUATOR maintains.

1. Title. That the article is a case report, with the phenomenon of greatest interest named, whether a symptom, diagnosis, intervention or outcome.
2. Key words. Two to five words capturing the key elements of the case.
3. Abstract. The background of why this case is unusual, the main symptoms and important clinical findings, the main diagnoses and interventions and outcomes, and the conclusion including the primary lesson.
4. Introduction. Brief background summarising why this case is unusual, with references.
5. Patient information. De-identified demographic details, the primary concerns and symptoms, and relevant medical, family and psychosocial history including diet, lifestyle, genetic information and any past interventions with outcomes.
6. Clinical findings. The relevant physical examination and other clinical findings.
7. Timeline. The episode organised as a chronology, which is usually best given as a figure or table.
8. Diagnostic assessment. The diagnostic methods used including examination, laboratory testing and imaging; the diagnostic challenges encountered; the diagnostic reasoning including the differential diagnoses considered; and any prognostic characteristics.
9. Therapeutic intervention. The types of intervention, whether pharmacological, surgical, preventive or self-care, and their administration including dose, strength, duration and frequency, with any changes and the rationale.
10. Follow-up and outcomes. The clinician and patient-assessed outcomes, the results of any follow-up testing, the extent of adherence and tolerability, and any adverse or unanticipated events.
11. Discussion. The strengths and limitations of the management of this case, the relevant medical literature, the rationale for conclusions including any assessment of cause and effect, and the primary lesson to be drawn.
12. Patient perspective. The patient sharing their own experience or perspective on the care they received, wherever possible.
13. Informed consent. A statement that the patient gave informed consent for publication, with the document available if requested.

The timeline item is the one that fixes the writing

Item 7 looks administrative and is in fact the most practically useful requirement in the checklist. Most hard-to-follow case reports are hard to follow because the chronology was assembled during writing, so the narrative doubles back: an investigation is mentioned, then a symptom that preceded it, then a treatment started earlier still.

Building the timeline first, as a table of relative times against events, forces the sequence to be settled before any prose exists. Use relative timing, such as day 1, day 4, month 3, rather than calendar dates, since precise dates are identifying information. Once that table exists, the case presentation almost writes itself, and the reader can see at a glance how long the diagnostic delay was, which is frequently the point of the report.

Consent and de-identification are separate obligations

This is where new authors most often get caught, sometimes after acceptance. De-identification means removing information that could identify the patient: name, initials, date of birth, precise dates, hospital identifiers, geographic location, occupation, and images showing identifiable features. It also means thinking about combinations, because a rare diagnosis plus an age plus a named region can identify someone even with no direct identifier present.

Consent is a separate requirement and is not satisfied by de-identification. Journals expect written informed consent from the patient, or from a next of kin or legal representative where the patient has died or lacks capacity, covering publication of the case including any images. Obtain it early. Discovering at proof stage that consent was never documented, with a patient who cannot now be contacted, ends the submission.

Consent is also distinct from authorship: a clinician who supplied the patient is not automatically an author, and the ICMJE authorship criteria set out what is. Note also that a case report is generally not human subjects research requiring ethics committee approval, though institutions differ and some require notification. Check your local requirement rather than assuming.

Where a case report sits, and how not to overclaim

A single case provides no comparison group, so it can establish that something happened and cannot establish that one thing caused another. This is the boundary most rejected reports cross, usually in the discussion, and usually through phrasing rather than a deliberate claim. "The patient improved following treatment X" is defensible. "Treatment X resolved the condition" is not, from n equals one.

Where causation is genuinely at issue, for example a suspected adverse drug reaction, the defensible approach is to reason explicitly about it: temporal relationship, response to withdrawal and any rechallenge, plausibility, and the exclusion of alternative explanations. Structured causality assessment frameworks exist for adverse drug reactions and citing one is stronger than an assertion.

The corresponding strength of case reports is worth remembering too. They are the mechanism by which genuinely new phenomena enter the literature at all, well before any design with a control group is possible, and a careful report of an unexpected harm can matter more than a large study of something already known, and it is often the first entry in what later becomes a full evidence synthesis. Our overview of how the evidence hierarchy works covers where single cases sit relative to synthesised evidence.

Completing the checklist

Work through the 13 items against your final draft, recording where each is addressed, and submit the completed checklist with the manuscript, since many journals now require it. Item 12, the patient perspective, is the one most often left out, and it is worth asking for: a sentence or two in the patient's own words about their experience is frequently the most memorable part of the report and is exactly what distinguishes a case report from a chart summary.

Before submitting, check the journal's own requirements alongside CARE. Case report word limits are tight, figure allowances are small, and several journals specify their own structure for the abstract. Reading common reasons manuscripts are rejected is a cheap final pass.