University of Maryland School of Medicine
Department of Physical Therapy & Rehabilitation Science
Clinical Education
Case Report Information
What is a Case Report?
A detailed narrative description of the management of a patient/client that may serve as
the basis for future research. A case report does not involve research methodology and is
considered a type of descriptive research.
(Jewell, D. V. (2008). Guide to evidence-based physical therapy practice. Boston: Jones
and Bartlett. )
 Notice location of Case
Report on Hierarchy of
Evidence
(http://library.fgcu.edu/RSD/Guides/HealthProfessions/Nursing/images/pyramid.jpg)
Sample Checklist
This is a sample checklist take from: McEwen. I. (2001). Writing Case Reports: A howto manual for clinicians. Alexandria, VA: APTA..
Introduction
 Convincingly explains the importance of the topic, citing credible literature
 Cites credible literature to support the intervention that was selected
 Cites credible literature to support importance of outcome measurements that
were used
 Leads clearly and logically to the purpose statement, which is made at the end
of the introduction
Case Description: Subject description/history and systems review
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Explains why this patient was selected for the case report
Includes relevant medical diagnoses
Provides relevant history, including demographic characteristics and pertinent
psychological, social and environmental factors
Describes prior or current services related to the current episode of physical
therapy
Explains co-morbidities that may affect the prognosis, anticipated goals and
expected outcomes and plan of care
Describes the patient’s desired outcomes
Case Description: Examination, evaluation, diagnosis and prognosis
 Clearly explains the rationale for using each test and measure
 Explains the examination procedures so clearly and thoroughly that other
clinicians could replicate them
 Addresses the reliability and validity of the measurements (cites published
reliability studies, provides the results of your own mini-reliability study, or
makes a presumptive argument)
 Clearly explains all examination data
 Clearly explains the decision-making process that led from examination through
the evaluation, diagnosis, and prognosis to the plan of care and the selection of
intervention
Case Description: Intervention
 Explains the intervention so clearly and thoroughly that another clinician could
replicate it
 Clearly explains the rationale for changes that are made in the intervention over
time
 Clearly explains the chronology of interventions and the changes in treatment
over time
 Clearly explains the amount of intervention (scheduled sessions, missed sessions,
etc.)
Outcomes Section
 Operationally defines the procedures used to obtain outcome measurements so
that another clinician could replicate these procedures
 Compares measured outcomes with the patient’s initial status
 Addresses the reliability and validity of outcomes measurements (may be
addressed under examination)
 Includes progress made toward the patient’s desired outcomes
Discussion
 Relates what happened to what others have reported in the literature
 Avoids suggesting that the intervention caused the outcomes
 Avoids generalizing to other patients
 Gives good suggestions for future research