In administering medical or laboratory test results, the medical practitioners or any healthcare professional are obliged to retain the confidentiality of the different medical reports. This is basically due to the fact that these are not just any kind of information that should be released to the public. Even though the patient or the participant is said to be a volunteer by singing the medical consent for this medical research project. Nevertheless, this act for information leakage is punishable by some legal actions that must be taken against the person responsible for the incident. In cases wherein the leakage or the information release is caused due to the medical or healthcare center’s negligence, they are held liable or accountable for this matter.
For every medical test that is conducted, every single detail must be documented using the case report form. This is in order for the practitioners to have an accurate basis for each of their simple medical report. In addition, documenting the small or little details puzzle out the complexity of the different cases that they encounter. Going further, provided for you in this article are few samples for case report forms that could help you apprehend the reasons or purposes why these kinds of reports are essentially utilized.
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What Is a Case Report Form?
A case report is referred to the clinical researches that are documented from the different case trials. The report is usually based on the actual observations and treatments, rather than the theoretical or laboratory studies. Thus, this kind of report contains all the uncovered information from the trial subjects, known as the patient or participant. As all the experimentation and clinical observations are performed, the findings or verdicts from the different tests are proven or manifested with the use of case report forms.
These case reports are often utilized for the following:
- conducting a research study in finding an effective cure for the newly discovered communicable or infectious disease
- treating or curing an infected patient
- experimenting and uncovering the symptoms from a particular disease
These case report forms are mandatory to be completed before each practitioner moves to the next case. Thus, all the gathered and collected data are considered significant for the completion or resolution of the current case/s. Yet, these case reports could not be concluded if these do not contain all the necessary and essential information. Therefore, refer below to know what the individual case report comprises. You may also see free incident report forms.
What Do Case Reports Contain?
These case reports are composed or consist of the following information:
- The patient’s demographic or personal information
- The full name of each patient
- The date of birth (mm, dd, yy)
- The exact residential and mailing address
- The contact number (at home, at work, and personal)
- The information of the emergency contact person (the name, active contact numbers, the address, and the relationship to the patient)
- The clinical information
- The consultation/s date
- The list of symptom/s onset
- The date for each symptom/s onset
- The brief description of the different symptoms
- The name, contact information, and address of the medical center
- The name and contact of the medical practitioner consulted
- The information of the prescribed medication/s
- The list of prescribed medication/s or treatment/s
- The specification of each medicine intake (such as the dosage of each, the number of daily intake, so on and so forth)
- The practitioner who gave or provided the different medication/s
- The case report details or information
- The disease name of the current case
- The contributing factors that lead to the case
- The reporting source of the case
- The date of when the case is reported
- The diagnostics or laboratory tests’ specifications
- The laboratory tests conducted
- The adverse events that resulted from different medical tests
- The specimens that were collected
- The results from the different laboratory tests based on the specimens collected
- The clinical notes or comments from the experimentation and observations of each trial subject
- The final and complete laboratory report
- The affixed signature of the person completing the case report
- The patient’s health care provider/s information
- The company or agency name
- The address of the health care provider
- The contact number and email address
- The name of the physician or general practitioner
In addition to these information listed above, the report form for each case also includes different questions that are used to complete the medical assessment of each trial subject.
- The physical examination of the individual
- The lifestyle of the patient or participant
- The past hospitalization records or reports
- The travel history or the information of the disease exposure
- The medication history which includes the duration (start and end date/s), the type of medication received, the number of medical intakes per day, the reason or purpose for such medication/s
All these information that are required should be used for medical purposes in order to solve each case. Thus, completing all the fields of information in the form brings the practitioner closer to resolving any kind of case reports, and that all information are made comprehensible to all authorized people. You may also like safety report forms.
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The Importance of Case Report Forms
In order to gain understanding with regards to the importance of case report forms, refer to the following list below.
- These case report forms help the practitioners integrate all the details to come up with the complete and accurate reports.
- These are utilized to ensure that each case is unraveled and resolved with the effective research information for cure, treatment/s, or remedy.
- With these report forms, practitioners are able to generate a more comprehensible report that is acceptable or understandable by everyone involved in the case.
- A complete case report helps the practitioners discover how hindrance or prevention is to be done, in order to avoid the worsening of each case. This is completed as soon as the reasons for such complications are identified.
- These case reports help the practitioners to be keen enough with regards to documenting even the little details.
- With the use of the case reports, it is ensured that all relevant information are secured and obtained in the form.
- By utilizing these reports, the standard and formal procedures of how each case should be treated is adhered.
- These forms for the different cases are to keep the confidentiality report of all the information that could be used against the patients, and/or the medical practitioners.
These are just few of the main reasons why these case report forms are fundamental, most especially when solving different cases or conducting clinical researches. You may also check out service report forms.
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Basic Tips in Utilizing Case Reports
In order to ensure the effectivity of each case reporting, you have to take heed of these different tips in utilizing and completing the case report forms.
- Make sure that you have all the necessary information. You may use a draft before you finalize all details in the form.
- See to it that all information that are to be written in the form are true, correct, and accurate based on the clinical observations.
- Before conducting any medical test, ensure that the trail subject or the patient has signed the informed consent form.
- It is important that everything is discussed with the patient. This includes the purpose of why the clinical researches should be done, the list of the tests that are to be conducted, the procedures that will be done, the possible outcomes, etc.
- Make sure that standard procedures are followed during the medical tests and observations.
- Do not forget to list even the single information from the case report.
- Make sure that the current case is solved before going to the next case.
- Ensure that only the authorized personnel or people are given access to these confidential information.
These are few of the basic tips that you could refer to when utilizing the case report forms. You may also see action report forms.
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Designing Case Report Forms
Refer to the following below for the different tips and guide in designing a case report form.
- Utilize or make use of the spaces provided in the form.
- Ensure that all fields of information are included in the form.
- All fields of information should be in order by categorizing them. An example is that the patient’s name, contact information, and address should be under the patient information category.
- You could make use of the check or tick boxes for the required information that has multiple answers.
- Ensure that the font size is uniform or standard, except for the title of the form.
- Make sure that the title of the form is indicated and emphasized.
- Also make use of lines or borders to separate or distinguish the different categories of information. Or better yet, make the form in a tabular format.
- Make sure that there are enough spaces for each information to be provided.
These are just few of the common tips you could take note of when designing a case report form. Nevertheless, refer to the different sample forms that are provided for you in this article in order to have more ideas on how you could efficiently design yours. You may also like audit report forms.
Technically, these case reports are used for documentation and references. Thus, these contain all the necessary information that each medical practitioner needs in order to decode and fathom the reasons behind the initiation of the different cases, and that effective medication is derived after few attempts in resolving each case of different trial subjects. You may also check out expense report forms.
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