CASE REPORT OUTLINE

 

Please submit a report with a minimum of 10,000 characters and a maximum of 15,000 characters (with spaces) of text (excluding appendices), double-spaced, in Times New Roman font size 12, with a margin of 1.0” on 8 ½” x 11” paper. 

  1. Name and Area of Specialization
  2. Case Log # (from Case Log Form)
  3. Date Patient Admitted
  4. Patient Name and/or ID#
  5. Patient Signalment
    1. Species
    2. Breed
    3. Age
    4. Sex
  6. Patient History
    1. Chief Complaint
    2. Current History
    3. Current Medication (including dosages if known)
    4. Pertinent Previous History
  7. Patient’s Status upon presentation
    1. Physical Examination

                                                              i.      Weight in kg

                                                            ii.      Temperature

                                                          iii.      Pulse rate +/or heart rate

                                                          iv.      Respiratory rate + character

                                                            v.      Level of Consciousness

    1. Body Systems Review of Abnormal Findings
    2. Problem List
  1. Differential Diagnosis
  2. Initial Assessment of Prognosis
  3. Initial Diagnostics & Results – Discussion of Test Selection, Alternatives or Suggested Procedures, Goals of Therapy
    1. Laboratory
    2. Diagnostic Imaging
    3. Procedures
  4. Daily SOAP Notes – Discussion of Case Management
    1. Subjective (for example: depressed, responsive, etc.)
    2. Objective

                                                              i.      Appetite, Eliminations

                                                            ii.      Vitals

    1. Medications – Dosage and Reason for Use
    2. Treatments – Discussion of Therapeutic Value

                                                              i.      Advanced Nursing & Technical Skills Performed

                                                            ii.      Advanced Nursing & Technical Skills Assisted With

    1. Assessment

                                                              i.      Pertinent Lab Results

    1. Plan
  1. Final Outcome
    1. Discharged

                                                              i.      Dispensed Medications and Dispensed Diets

                                                            ii.      Home Nursing Instruction

    1. Euthanized or Expired: Necropsy Results if Applicable
  1. Discussion of Case – Pathophysiology, Disease Process, Etiology
  2. Laboratory and Diagnostic Reports - all laboratory and diagnostic reports are to be included in the appendix, and are not to be counted in the total number of characters of the case report.