I was recently prompted to revisit the issue of informed consent for case reports when several authors requested a patient consent form. All clinicians and researchers are aware of the regulations governing identifiable information in any such writings; e.g., name, birth date, MRN, both in text and images. But I took a step back and did some deeper research into vetting case reports before submission and the growing emphasis on patient consent.
Other information that might be considered identifiable could include photos that show tattoos or other unique physical characteristics, a radiographic image showing an obvious anomaly, or text that mentions a patient’s occupation or even their geographic location. These bits of information might be crucial to the description of a rare or unique case report and its outcome, but a number of salient facts combined may well lead to personal identification with relatively simple online searching.
Although a number of journals provide consent forms for case reports, not all require consent to be noted in the report itself. Forms are not submitted to the journal and most suggest authors acquire consent and keep it on file.
The U.S. Department of Health & Human Services offers specific guidance for deidentification, and Elsevier, one of the largest publishers of medical and scientific journals, offers tips for writing case reports, but also details their requirements for consent for their journals.
University of Iowa Health Care does not currently offer a consent form specifically for case reports, but Molly Rossiter, Communications Specialist with UIHC Marketing and Communications, advised me that authors should use the current UIHC photo consent form with a case report addendum until an approved consent form specific for case reports can be released. I have created an addendum to the standard photo consent and this form can be used for patients in case reports or case series – available for download here.
As always, I am happy to assist with all scholarly writings, including case reports, as well as manuscripts, grants, CVs, biosketches, patient materials, and correspondence. Feel free to contact me at firstname.lastname@example.org. Helpful general tips for manuscript writing are also available on my web page.