Linee Guida Casi Clinici
- Nella prima riga di ogni report dovranno comparire il nome e cognome dell’autore e del paziente. Es: Mario Rossi – Lucky
- Per quanto possibile, il report dovrà essere suddiviso nelle sezioni seguenti (da www.avma.org):
Statement of the Problem, Signalment, History, Physical Examination Findings and Laboratory Results, Diagnosis, Treatment, Follow-up and Discussion/Conclusions. The Statement of the Problem should be a brief, 1- or 2-sentence description of the behavioral problem for which the patient was evaluated. The Signalment should be stated as a single sentence including age, sex, breed, species, and body weight if applicable. The History section should include any pertinent background information related to the patient and the problem for which it was evaluated, and it should be presented in a chronological manner. The Physical Examination Findings and Laboratory Results should describe the examination and any tests performed as part of the patient evaluation. The results, including any abnormal findings, should be summarized in the text; pertinent laboratory abnormalities should include mention of the reference range for the given variables. Tables of test results such as hematologic and serum biochemical values are generally not needed. The Diagnosis portion of the manuscript should include a description of any differential diagnoses, additional steps taken to determine the diagnosis or diagnoses, and rationale for the diagnoses made. The Treatment section should briefly describe the treatment provided (including any medications and recommendations for behavioral monitoring, behavioral modification, and follow-up). The Follow-up section should describe the clinical course of the condition, subsequent alterations to the treatment plan, and condition at last follow-up. The Discussion/Conclusions section.