Formal Case History Rubric

The following components should be included in the write-up of a formal case history.

1. Title of Case History
2. Your name
3. Date of Case History Write Up
4. Abstract: A condensed version of the full text of the case study, representing details of the case sufficient to be used as an introductory ‘teaser,’ which is used in our newsletter opening page.
5. Patient’s initials, alias, or code (Do not use patient’s actual name.)
6. Chief Complaint: What was the reason the patient came in to see you?
7. Narrative of patient's present condition
8. Medical History: What other symptoms or conditions has the patient experienced?
9. Subjective findings
• What signs and symptoms did the patient report?
10. Objective findings
• What data was obtained by physical examination?
• Tongue, pulse, et al.?
• Palpation?
• Orthopedic or neurological testing?
• What were the patient’s vital signs (body temperature, respiration rate, pulse rate, blood pressure, O2 saturation)?
• Patient’s height and weight?
• Laboratory data?
• Imaging results?
• Reports from other clinicians?
11. Assessment/Diagnosis
• TCM diagnosis
• Biomedicine diagnosis including ICD-10 code.
12. Biomedicine Discussion, including optional or recommended biomedicine treatment options.
13. Treatment Plan: Use Chinese medicine language predicated on TCM diagnosis
14. Treatment specifics including rationales. Including, but not limited to the following as applicable:
• Acupuncture
• Moxa
• E-stim
• Chinese herbs
• Dietary supplements
15. Other therapeutic recommendations including, but not limited to:
• Dietary
• Exercise
• Lifestyle changes
16. Conclusions and discussion
17. References (include all sources consulted)