Case Report

Brieflands recommends that authors of case reports follow the CARE guidelines (CAse REport), the international reporting standard for case reports. Following CARE makes the case easier to assess in review and easier to use by other clinicians.

Patient consent — required, no exceptions

Written, signed consent for publication is required for every case report and case series. Obtain it from the patient, or from the legal guardian where the patient is a minor or unable to consent, and where the patient has died or cannot be traced, from the next of kin. Upload the signed form at submission and state in the manuscript that consent was obtained. The related requirements in the ethical oversight policy also apply.

A case report cannot be published on the grounds that the patient is unidentifiable instead of on consent. De-identification is a separate duty, not a substitute for consent.

De-identify before you submit

• Remove names, initials, hospital and record numbers, and any local identifier.
• Replace exact dates with intervals (“three weeks after admission”), and give age as a range where the exact age could identify the patient.
• Remove identifying detail from images, scans and pathology slides, including burnt-in patient data and institutional marks. Crop or mask the whole identifying region — an eye bar alone is not de-identification.
• Do not alter or retouch a clinical image to obscure identity in a way that changes what it shows.
• Check file names and document properties, which frequently carry patient or hospital identifiers.

Rare conditions, unusual presentations and small communities can make a patient identifiable even after these steps. Where that risk remains, consent is the only basis on which the report can be published.