医疗报告结构与来源检查

references/case_report_guidelines.md

Current source

The official CARE site continues to identify the 2013 CARE Checklist as the core checklist. The 2017 explanation and elaboration supplies rationale and examples. CARE is reporting guidance for case reports; it does not authorize record access, establish consent, prove de-identification, or replace journal instructions.

Thirteen checklist headings

Preserve the official structure:

1. title;
2. key words;
3. abstract;
4. introduction;
5. patient information;
6. clinical findings;
7. timeline;
8. diagnostic assessment;
9. therapeutic intervention;
10. follow-up and outcomes;
11. discussion;
12. patient perspective;
13. informed consent.

Use the official checklist and explanation for subitems. The local validator checks only that all headings have an allowed status and verified fact references; it does not judge clinical accuracy or CARE adherence.

Safe use

• Begin with assets/case_report_template.json.
• Use de-identified source facts, not copied charts or free-text records.
• Keep direct identifiers and contact details out of the draft manifest.
• Represent chronology with relative study/case offsets when authorized and scientifically adequate; do not alter chronology to disguise conflicts.
• Preserve diagnostic and therapeutic statements as attributed facts from authorized records. Do not independently diagnose, rationalize treatment, or recommend care.
• Attribute the patient perspective to an authorized source; never invent a quote.
• Keep uncertainty, missing follow-up, adverse outcomes, and limitations visible.
• Do not claim novelty until an accountable author has reviewed the literature.
• Avoid causal or general treatment claims from a single case.

Consent and privacy

CARE includes informed consent as an item, but a template cannot obtain or verify consent.

• Record only a consent status verified by the responsible human reviewer.
• Do not create a stock statement asserting that consent was obtained.
• Consent for publication and HIPAA de-identification are separate questions.
• De-identification does not necessarily remove all re-identification risk, particularly for rare conditions, small communities, images, unusual timelines, or distinctive combinations.
• Journal, institution, law, ethics-board policy, and circumstances involving minors, deceased persons, or persons unable to consent require qualified review.

Fail-closed statuses

Each CARE item uses one of:

• verified_present — supported by one or more verified source-fact IDs;
• not_applicable_with_rationale — a qualified reviewer supplied a recorded rationale;
• missing — blocks structural readiness;
• conflict — source records disagree and human resolution is required.

The consent item cannot be waived by the script. A missing or unresolved consent status blocks publication handoff.

Qualified review

Before any journal handoff, accountable authors and the appropriate clinical, privacy/legal, and institutional reviewers must verify:

• source accuracy and chronology;
• consent and authorization;
• privacy and image/metadata handling;
• terminology and clinical interpretation;
• discussion claims and citations;
• conflicts, limitations, and adverse outcomes;
• the target journal’s current instructions.

A structural result of STRUCTURE_COMPLETE_REVIEW_REQUIRED is not permission to submit.