Preparation of the Manuscript

Literature Search and Data Sources

In a short paragraph, please succinctly describe your search strategy, the key word(s) used, the date(s) of the search, and the data sources you accessed in identifying the highest quality evidence on your topic. By "data sources," we mean sources such as Cochrane, Clinical Evidence, and the National Guideline Clearinghouse. Do not list the actual references you found in each source; simply include them in your bibliography.

We strongly recommend that you search the following freely accessible evidence-based sources of information and also consult our EBM Toolkit.

Websites for Sources of Evidence-Based Clinical Information:

Free Access


McMaster University’s compendium of pre-appraised evidence to support clinical decisions.  Content is presented in a hierarchical way, with the highest level of available evidence listed first.

Agency for Healthcare Research and Quality(
In particular, see AHRQ’s Effective Healthcare Reports( on various clinical topics.
Note: many of  these reports are published in AFP under the “Implementing AHRQ Effective Health Care Reviews” department collection.

Cochrane Database of Systematic Reviews(
Free for abstracts only, which in most cases provide the key findings of interest. The complete review requires a subscription. The Cochrane database contains systematic reviews of narrowly focused clinical questions (e.g., “Colchicine for treating acute gout attacks”) as opposed to broad, general reviews of topics (e.g., “Management of an acute gout attack”).
Note: AFP publishes summaries of Cochrane abstracts in “Cochrane for Clinicians.”

ECRI Guidelines Trust(

Repository of evidence-based clinical practice guidelines, appraised using the National Academy of Medicine’s Standards for Trustworthy Clinical Practice Guidelines. 

National Center for Complementary and Integrative Health(
Although NCCIH has been criticized for political interference and questionable science, we include it in this list because there are few freely available comprehensive sources of information in this field.

Trip( (Turning Research Into Practice)
Contains links to a wide range of journal articles, medical organization clinical guidelines, online medical references, and other sources.  A limited version is freely available; additional content requires an annual subscription.

U.S. Preventive Services Task Force(
Premier source of evidence-based, graded recommendations for clinical preventive services.
Note: AFP publishes Recommendations and Reports from the USPSTF as well as CME case studies in the Putting Prevention Into Practice series.

Subscription Required

Most of these are point-of-care clinical information and decision support tools. These sites provide important background information, but authors should review the primary source to use as a citation for the article.


Essential Evidence Plus(
Includes POEMS (collections of patient-oriented evidence that matters).

Natural Medicines Comprehensive Database(
Reviews of the use of natural medicines in the treatment of various diseases.

Natural Medicines(
Database of dietary supplements, natural medicines, and complementary, alternative, and integrative therapies.



To ensure adequate searching on your topic, we strongly recommend that  the above sources be reviewed, in addition to a PubMed search using the Clinical Query function( This is done by using the provided link, or by going to the PubMed home page, and selecting “Clinical queries” from the lower center of the screen.

Sample Data Sources paragraph:

Data Sources: A PubMed search was completed in Clinical Queries using the key terms gout and hyperuricemia.  The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were the Agency for Healthcare Research and Quality Effective Healthcare Reports, the Cochrane database, DynaMed, and Essential Evidence Plus. November 18, 2017.

Manuscript Format

Manuscripts formatted to conform to the “Uniform requirements for manuscripts submitted to biomedical journals( are acceptable for submission. AFP endorses these guidelines. Format the manuscript with margins of 1 1/2 inches on all sides. Double-space the entire manuscript, including components, and arrange the manuscript in the following sequence, with each section beginning on a new page:

  • Title page
  • Abstract
  • Text
  • Literature Search and Data Sources
  • References
  • Tables, including an Evidence Table (each table begins on a new page)
  • Figures
  • Acknowledgments
  • Biographic sketch

The title page, abstract, text, references, and tables should be contained in a single word processor document, ideally in Microsoft Word (DOC) or Rich Text Format (RTF). The acknowledgments and the biographic sketch should be in a separate file in order to accommodate blinded peer review. Each figure should be submitted as a separate computer file as described in this document under Figures.

Number pages consecutively in the upper right-hand corner, beginning with the title page. To accommodate blinded peer review, place the names of authors only in the biographical sketch for each author. See the section on Submitting the Manuscript for details on how to submit your manuscript to AFP.

Please carefully review the detailed instructions for each section that follows:

Title Page

This page should contain only the title of the manuscript and the word counts (word count for the entire manuscript and word count for text only--excluding abstract, references, tables, figures). This is to facilitate blinded peer review of the manuscript in the Editorial Manager system. Pertinent information such as names of authors, institutional affiliation, and contact information is entered into Editorial Manager by the authors and will be placed in a pre-formatted cover sheet for editorial use.

Sources of support in the form of grants, equipment, or drugs should be mentioned in the Conflict of Interest Form(2 page); this information will be included as a footnote to the article. For details, see the Conflict of Interest section.


Include an abstract of 150 to 250 words, depending on the length of the text. The abstract should provide factual and specific (rather than general and nonspecific) information summarizing the main points of the manuscript. For example, instead of saying, “This article will describe the differential diagnosis of chest pain in adolescents,” say, “The most common causes of chest pain in adolescents include musculoskeletal strain, hyperventilation syndrome, and anxiety.” For clinical reviews, highlight key points in the diagnosis and treatment of the condition discussed.


Article length should be 1,500 to 1,800 words (maximum 2,000 words, about six to eight manuscript pages of text), not including the title page, abstract, tables, reference list, etc. Manuscripts of more than 2,000 words of text are rarely accepted.

Do not include a summary or conclusion section in your manuscript; anything that you would ordinarily put in such a section should go into the abstract.

Provide appropriate reference citations to support key clinical recommendations, statistical information, reports of previous studies, controversial statements, etc. Use the following guidelines in choosing references:

  • Avoid citing other clinical review articles—you should emphasize original research articles, systematic reviews, Cochrane Library reviews, citations from BMJ’s Clinical Evidence, validated clinical decision rules, randomized trials, and evidence-based practice guidelines where possible. Clinical review articles may be cited as sources for tables, figures, or general background information.
  • Emphasize recent references (within the past 10 years); in general, avoid letters to the editor, editorials, and references that are older than 10 years or of historic interest only.
  • Avoid references from obscure or non–English-language journals.
  • Do not cite abstracts, unpublished observations, manuscripts in preparation or submitted for publication, or personal communications.
  • To avoid plagiarism, do not to use the language, content, or concepts of another source without an appropriate reference. Do not use extensive verbatim or near-verbatim portions of text from another source, even with appropriate citation.

Begin the writing process by identifying key clinical questions and controversies related to your topic, and then answer them with the best available evidence. Do not write the article and then find selected references to support your opinions!


Please number references in the text in the order of citation. Use double-line spacing in your reference list; arrange references numerically, not alphabetically. Do NOT use "Endnotes" or any other automated reference function in any word processor.

Titles of journals should be abbreviated according to the style used in PubMed( If there are six or fewer authors, list them all; if there are more than six, list the first three followed by "et al." Please note that no periods are used after the authors’ initials. Include beginning and ending page numbers for journal and book references. The average number of references for a full-length article ranges from 15 to 30. Most articles will not exceed 35 references.

References first cited in tables or figure legends must be numbered to remain in sequence with references cited in the text. Note the following examples of reference style:

Standard Journal Article

  1. Weiss BD. Nonpharmacologic treatment of urinary incontinence. Am Fam Physician. 1991;44(2):579-586.
  2. Gold D, Bowden R, Sixbey J, et al. Chronic fatigue. A prospective clinical and virologic study. JAMA. 1990;264:48-53.

Chapter in a Book

  1. Murray JL. Care of the elderly. In: Taylor RB, ed. Family Medicine: Principles and Practice. 3rd ed. New York, NY: Springer-Verlag, 1988:521-532.


  1. BMJ Publishing Group. Clinical evidence on tinnitus. Accessed November 12, 2013.


Authors should maximize the educational value of tables. Give complete reference data for each item in a table. For all tables that are borrowed or adapted from other sources, include scanned photocopies of the tables as they appeared in the original source, making sure that complete reference data are included for the original source.

Do NOT attempt to obtain reprint permission from the original publisher. AFP will seek permission from the copyright owner to publish the material in print and other formats. However, it is possible that the rightsholder will not grant permission for use of copyrighted materials, and AFP reserves the right to withhold tables or figures from print and other formats based on the rightsholder’s terms. Due to the increasing difficulty with obtaining permission to adapt previously published material, we strongly encourage authors to create original tables and figures. See Tips for Creating Original Tables and Algorithms(1 page PDF) and How to Create an Algorithm in Word(6 page PDF). Note that tables and figures that were previously published, and for which we obtain reprint or adaptation permission, must be removed from AFP articles sent to content aggregators, such as EBSCO and MDConsult.

Tables should be interpretable without reference to the text. Each table should have a title and be numbered sequentially with Arabic numerals. Put each table with double-line spacing on a separate page. Use the “Tables” function of your word processor to create the table rather than just using spaces and tabs (which quickly get out of alignment as the manuscript is transferred into other computer formats). In general, make tables part of your main document rather than creating a separate file for each table.

For tables that include drug pricing, please use information from GoodRx ( to find representative undiscounted prices, not using GoodRx coupons.

Clinical Decision Tools: Please mention and include links to relevant clinical decision tools and calculators, especially those published in AFP’s Point-of-Care Guides ( and on the medical calculator website MDCalc (

Costs of laboratory tests, imaging studies, and clinical procedures: Where relevant, please include approximate, representative costs for tests or procedures, especially in tables where comparative cost is discussed.  We use Healthcare Bluebook as the source for pricing when possible:  If you use another source, please provide a complete citation for it.

SORT: Evidence Table of Key Clinical Recommendations

We would like each article to include an Evidence Table (also called “SORT” or “Strength of Recommendations Table”). This table will help readers understand the main points of your article, and the strength of evidence that supports its recommendations. The table should contain the key clinical recommendations and strength of recommendation ratings for your article as shown in the sample below:

Clinical recommendationEvidence ratingComments
Clinical recommendation: Obtain an ECG in patients presenting with chest pain.1,2Evidence rating: CComments: Recommendation from consensus guideline based on observational studies
Clinical recommendation: Patients with two normal highly sensitive troponin tests an hour apart can safely be sent home.10Evidence rating: BComments: Meta-analysis of randomized trials
Clinical recommendation: Patients with chest pain should immediately receive oxygen and if not allergic an aspirin tablet.17,18Evidence rating: AComments: Consistent findings from randomized controlled trials and recommendation from evidence-based practice guideline
Clinical recommendation:

ECG = electrocardiogram.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to

The SORT table is intended to highlight the most important three to seven recommendations from your article for clinicians. Each recommendation must be accompanied by a SORT rating of A, B, or C. Your recommendations should emphasize interventions and approaches that improve patient-oriented outcomes (e.g. morbidity, mortality, quality of life) over disease-oriented evidence (e.g. biomarkers, surrogate endpoints).

  • You should have three to seven recommendations. Try to identify a range of recommendations, for example, one each about screening, prevention, diagnosis, and two about treatment.
  • Each statement should be in the form of a recommendation and should not just present a fact or piece of medical trivia. For example, “Use the Wells score to determine the risk of DVT in patients with leg pain” is a recommendation, while “Of patients presenting with leg pain, 16% have a DVT” is not.
  • An “A” recommendation should be based on consistent evidence of improved patient-oriented outcomes from well-designed studies. Use clear, directive language as this is a recommendation that should be applied to most patients, such as “Patients age 50 to 74 years should receive screening for colorectal cancer."
  • A “B” recommendation is based on lower quality evidence of improved patient-oriented outcomes or inconsistent evidence. These statements should use language such as “Consider…” or “…is a practice option” or “…may be effective.”
  • A “C” recommendation is often something that is standard of care, but for which there have been no clinical trials or trials have only reported disease-oriented outcomes. In this case, the recommendation statement should reflect the strength of recommendation, and the “Comment” column should clarify that this is a recommendation “based on expert opinion in the absence of clinical trials” or “based on evidence from clinical trials with blood pressure reduction as the outcome.”

If you are not comfortable assigning the strength of recommendation (below), our medical editors will do that for you.

To rate the strength of evidence supporting key clinical recommendations, please use the following guidelines:

STRENGTH OF RECOMMENDATION: ADEFINITION: Recommendation based on consistent and good quality patient-oriented evidence*
STRENGTH OF RECOMMENDATION: BDEFINITION: Recommendation based on inconsistent or limited quality patient-oriented evidence*
STRENGTH OF RECOMMENDATION: CDEFINITION: Recommendation based on consensus, usual practice, expert opinion, disease-oriented evidence,** and case series for studies of diagnosis, treatment, prevention, or screening
STRENGTH OF RECOMMENDATION: * Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life.
** Disease-oriented evidence measures intermediate, physiologic, or surrogate endpoints that may or may not reflect improvements in patient outcomes (e.g., blood pressure, blood chemistry, physiological function, and pathological findings).

Use the table below to determine whether a study measuring patient-oriented outcomes is of good or limited quality, and whether the results are consistent or inconsistent between studies:

Type of Study
Study QualityDiagnosisTreatment/Prevention/ScreeningPrognosis
Study Quality: Level 1 Good quality patient-oriented evidenceDiagnosis: Validated clinical decision ruleTreatment/Prevention/Screening: Systematic review/meta-analysis of randomized controlled trials (RCTs) with consistent findingsPrognosis: Systematic review/meta-analysis of good quality cohort studies
Study Quality:  Diagnosis: Systematic review/meta-analysis of high quality studiesTreatment/Prevention/Screening: High quality individual RCT +Prognosis: Prospective cohort study with good follow-up
Study Quality:  Diagnosis: High quality diagnostic cohort study *Treatment/Prevention/Screening: All or none study ++Prognosis:  
Study Quality: Level 2 Limited quality patient-oriented evidenceDiagnosis: Unvalidated clinical decision ruleTreatment/Prevention/Screening: Systematic review/meta-analysis of lower quality clinical trials or of studies with inconsistent findingsPrognosis: Systematic review/meta-analysis of lower quality cohort studies or with inconsistent results
Study Quality:  Diagnosis: Systematic review/meta-analysis of lower quality studies or studies with inconsistent findingsTreatment/Prevention/Screening: Lower quality clinical trial +Prognosis: Retrospective cohort study or prospective cohort study with poor follow-up
Study Quality:  Diagnosis: Lower quality diagnostic cohort study or diagnostic case-control study *Treatment/Prevention/Screening: Cohort studyPrognosis: Case-control study
Study Quality:  Diagnosis:  Treatment/Prevention/Screening: Case-control studyPrognosis: Case series
Study Quality: Level 3 Other evidenceDiagnosis: Consensus guidelines, extrapolations from bench research, usual practice, opinion, disease-oriented evidence (intermediate or physiologic outcomes only), and case series for studies of diagnosis, treatment, prevention, or screening.

* High quality diagnostic cohort study: cohort design, adequate size, adequate spectrum of patients, blinding, and a consistent, well-defined reference standard.
+ High quality RCT: allocation concealed, blinding if possible, intention-to-treat analysis, adequate statistical power, adequate follow-up (> 80%).
++ An all-or-none study is one where the treatment causes a dramatic change in outcomes, such as antibiotics for meningitis or surgery for appendicitis, which precludes study in a controlled trial.

Consistency Across Studies

Most studies found similar or at least coherent conclusions (coherence means that differences are explainable).


If high quality and up-to-date systematic reviews or meta-analyses exist; they support the recommendation.


Considerable variation among study findings and lack of coherence.


If high quality and up-to-date systematic reviews or meta-analyses exist, they do not find consistent evidence in favor of the recommendation.

Please use the following algorithm for determining the strength of a recommendation based on a body of evidence (applies to clinical recommendations regarding diagnosis, treatment, prevention, or screening). Although this provides a general guideline, authors and editors should adjust the strength of recommendation based on the benefits, harms, and costs of the intervention being recommended. Again, if you are unsure how to apply these ratings, the medical editors will do this for you. At a minimum, you should create a summary table with recommendations and references for each recommendation.

For more information on how to apply these ratings, please see the explanatory article published in the February 1, 2004, issue of American Family Physician.


AFP encourages the submission of original figures that clarify the text. The term "figures" refers to illustrations, photographs, radiographs, scans, sonograms, diagrams, graphs, flow charts, algorithms, etc. AFP requires authors to transfer copyright ownership of original figures to the AAFP. For all figures that are borrowed or adapted from other sources, include scanned photocopies of the figures as they appeared in the original source, making sure that complete reference data for the original source are included. Clearly identify figures that have not been previously published and are supplied by a person other than the author and include complete contact information for the owner of the material. For figures supplied by your institution or a colleague, clearly indicate whether that institution/person is retaining copyright (in which case we will need to contact them) or if copyright is being transferred to AFP with the article.

Do NOT attempt to obtain reprint permission from the original publisher. AFP will seek permission from the copyright owner to publish the material in print and other formats. However, it is possible that the rightsholder will not grant permission for use of copyrighted materials, and AFP reserves the right to withhold tables or figures from print and other formats based on the rightsholder’s terms. Due to the increasing difficulty with obtaining permission to adapt previously published material, we strongly encourage authors to create original tables and figures. See Tips for Creating Original Tables and Algorithms(1 page PDF) and How to Create an Algorithm in Word(6 page PDF). Note that tables and figures that were previously published, and for which we obtain reprint or adaptation permission, must be removed from AFP articles sent to content aggregators, such as EBSCO and MDConsult.

Each figure should be submitted as a separate digital file and numbered sequentially as it appears in the text. Diagnostic images (e.g., ECGs, sonograms, radiographs), artwork, line drawings, and nondigital photographs should be scanned at a resolution of at least 600 DPI before submission and saved as TIFF files. Only the following file formats are acceptable; others will be returned to the author for reformatting and resubmission.

  • TIFF (Tagged Image File Format)
  • PowerPoint (acceptable only for tables or algorithms; not acceptable for imported images)
  • JPG (only high-resolution images of at least 300 pixels or dots per inch [ppi or dpi])

Image resolution is typically measured in pixels per inch, or ppi (some use the term "dots per inch," or dpi). The image’s resolution and its dimensions determine the overall file size of the image, as well as the quality of the output. While images with a resolution of 72 ppi (28.35 pixels per cm) are adequate for materials posted on the Web, this resolution is inadequate for print media. If your file size is less than 200 kb, it is almost certainly of too low a resolution for a print journal. For color and grayscale images of 3 to 5 inches, we recommend a resolution of 300 ppi (118.11 pixels per cm). Line drawings in black and white require a higher resolution of 600 ppi (236.22 pixels per cm). An image generated by a digital camera as a 72 ppi JPEG file may still be acceptable if it measures at least 14 inches wide or high.

We strongly prefer original photographs/images, because images downloaded from websites or taken from other publications rarely reproduce well, even if we are able to obtain permission to reprint them.

Because the quality of original illustration varies, it may be necessary to have the art you supply redrawn to meet AFP’s artistic standards. AFP’s art department is available to assist authors in the creation of original, high-quality artwork to illustrate manuscripts accepted for publication. This service is provided at no charge to authors but is subject to editorial judgment.

Other guidelines for artwork include the following:

  • Symbols, lettering, and arrows in figures should be clearly marked and large enough to remain legible if the size of the illustration is reduced for publication.
  • Photographs in which a patient is identifiable MUST be accompanied by the patient’s written permission for publication(1 page PDF). "Identifiable" means that the person in the photo (or a parent of a child subject) could reasonably be expected to recognize himself/herself. A bar obscuring the eyes does not provide adequate anonymity and is not acceptable [see NEJM, August 24, 1989, p. 550].
  • Because of the poor quality inherent in reproducing previously published images, photographs and radiographic images from textbooks and journals cannot be reproduced in AFP, regardless of whether permission has been obtained from the publisher.
  • Do not save images within a Microsoft Word or PowerPoint document or use the “Drawing” features of your word processor.
  • The legends for each figure should be typed with double-line spacing and combined on a separate page at the end of the manuscript.

If you are submitting figures in digital format, save each figure as a separate file. Each file should be saved with a name that includes the AFP manuscript number and figure number as referenced in the manuscript. Files should be uploaded at the time of manuscript submission in AFP's Editorial Manager site( ( and clearly labeled.

Acceptance of a manuscript for publication is contingent on provision of artwork that meets the above specifications. If you have any questions about the preparation of art or digital images for your manuscript, contact Dave Klemm, AFP Medical Art Coordinator, at After your manuscript has been accepted for publication, address questions about art to the medical editor.


You may acknowledge professional help in the preparation or review of your manuscript. Written permission is required to publish the names of persons acknowledged. See Author Statements Form(1 page PDF).

Biographic Sketch

Please complete a brief Biographic Sketch form for each author, which includes information on medical training, current position, and academic appointments.

Author's Guide References

  1. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Accessed June 17, 2010.