Health Information Management and Medical Records Case Studies
Healthcare5 Case StudiesUpdated Sep 2026
This set of five cases follows health information management from a record that is only a partial picture to the decision it shapes. Each case centers on a fictional organization and a choice that a care team had to make with incomplete or conflicting information. Pay attention to who holds which piece of the record, what local protocols require, and where handoffs between people and systems quietly lose something important. The analysis paragraphs model the reasoning an experienced records lead or charge nurse would bring to the same problem, aiming for a process that holds up on review.
Case Study 1
A slow drift in observations on a medical ward
Larkspur Valley Community Hospital, a 210-bed acute care hospital serving a mixed rural and suburban catchment
The situation
Ruth, a 68-year-old patient on the fourth floor medical ward, was admitted after several days of fatigue and poor appetite at home. Over the first two days, the nursing flowsheet recorded a slow rise in heart rate and respiratory rate, a small increase in supplemental oxygen, and urine output that was charted inconsistently. Each set of observations stayed under the threshold for urgent review. The early warning score moved from 2 to 5 across six checks, but the change was spread across three nurses and two shifts. The admitting notes described her as stable, written before the trend began, and laboratory results sat in a separate system that the team checked mainly at rounds.
The challenge
Dimitri, the charge nurse on the ward, noticed the pattern during afternoon handover and had to decide whether to call the on-call physician now or wait for morning rounds. The decision required weighing the observations against the escalation criteria in the deterioration protocol, choosing which investigations to request first, and stating plainly what the team was worried about. Nobody had yet written the trend down as a single statement.
Analysis
The clinical question here is about direction, not any single value. A heart rate or respiratory rate that sits just below the trigger on one check can still be the first point on a line that is climbing. Ruth's oxygen requirement was small but its direction mattered more than its size, and the urine output gap meant the team could not say whether her intake and output were changing in step with her appetite. Reading the flowsheet as a series, and treating missing entries as data, is the habit that matters here. Before judging urgency, the team needs to know what was measured, what was not, and when.
Teams grounded in Health Information Management and Medical Records usually start by naming who owns each part of the decision. Here the deterioration protocol gave the charge nurse authority to call for review once a trigger was met, but it did not say what to do when a trend developed below every trigger. That gap is where the delay lived. A better call to the on-call physician would have described the direction of change, the gaps in charting, and a specific request, such as repeat observations at a stated interval. Escalating on a trend needs local agreement, and that agreement belongs in the protocol so the next nurse does not decide alone.
- Day one, admissionObservations within thresholds, oxygen need small and new.
- Day one, eveningHeart rate creeping upward, urine output charted incompletely.
- Day two, earlyEarly warning score reaches 4, still below urgent review.
- Day two, afternoonScore reaches 5; handover describes trend but no call made.
- Day two, eveningCharge nurse calls physician; pending results reviewed.
Actions taken
- Write a single trend statement at each handover that names the direction of change, the time range, and the observations involved, so that no one has to reconstruct it from the flowsheet.
- Agree with the medical leads that a sustained directional change across two or more checks counts as a trigger for call-back, and add that wording to the deterioration protocol after review.
- Set a ward standard that missing urine output entries are flagged in the handover tool within the same shift, and assign the charge nurse to review gaps at mid-shift.
- Make laboratory results that are pending or unreviewed visible on the ward dashboard, so the team sees them between rounds instead of only during them.
Results
The charge nurse called the on-call physician before the evening round, described the trend in a single sentence, and asked for review. The pending laboratory results were reviewed, and the physician revised the monitoring plan that evening. The episode review found that the trend had been visible in the flowsheet for about a day before the call. The protocol amendment with explicit wording on sustained directional change was approved by the end of the quarter, and a ward audit in the following quarter found trend statements in 19 of 24 handovers, up from 4 of 22 before the change.
Questions for discussion
- Which parts of Ruth's record would you want to see before deciding whether the trend warranted a call, and who on the team holds each of them?
- How should a protocol treat a directional change that stays below every individual trigger, and what local agreement would make that escalation safe for a newer nurse?
- When a charge nurse and an on-call physician disagree about urgency, what should the record show about the reasoning on each side?
Case Study 2
A handover gap that left a fall risk unseen
Ashgrove Regional Health, a network of two acute hospitals with a shared electronic handover tool
The situation
Ibrahim, a 79-year-old patient, was moved from the emergency department to a medical unit at the end of the evening. The verbal handover from the emergency nurse, Priya, covered his working diagnosis, his observations and the plan for admission. It did not mention that his fall-risk score had been raised earlier in the day, that a consultant review was pending for the following morning, or that his mobility aid had been left in the emergency department. The unit's electronic handover tool had a field for fall risk, but the nurse completing it used the verbal summary and left the field at its default. Nobody on the receiving team had seen the earlier risk assessment.
The challenge
Tomasz, the night charge nurse, had a handover that looked complete and a patient whose risk status he had not yet seen. The team had to check what else had been left out of the transfer, and decide which safeguards would stop the same gap from repeating on the next admission from the same department. Before the first round, the team also had to decide whether the patient needed closer observation and whether the consultant review could be brought forward.
Analysis
Ibrahim's needs were clearer on paper than in practice. An older adult who has moved between settings within one day carries risk that a diagnosis label does not capture, and the fall-risk score was the only piece of evidence that spoke to his mobility specifically. The score had been recorded in the emergency record, so the evidence existed. What was missing was its route into the place where decisions were made overnight. A verbal summary can be accurate in its content and still fail to carry the things a receiving nurse would act on, especially when they sit in a separate system.
Most transfer protocols assume that the sending team's summary and the written record say the same thing. In this case they did not, and the protocol had no step that forced someone to check. The unit's handover standard asked for a structured tool, but the tool allowed a field to stay at its default without a prompt. A stronger practice would have the receiving nurse read the risk fields aloud before the sending nurse leaves, and would list the pending review as a named checklist item. Most gaps of this kind are ordinary omissions, and the fix is usually a forcing function rather than another reminder.
Actions taken
- Add a required risk-field confirmation to the electronic handover tool so that a default value cannot be saved without a clinician stating the score or marking it not assessed.
- Require the sending nurse and receiving nurse to read the fall-risk and pending-review fields together at the bedside, and record both names against the handover.
- Create a shared list of pending specialist reviews for each bed, visible from the emergency department and the medical unit, and review it at every shift change.
- Track handover omissions for ninety days with an audit form, aiming for no more than 2 missing risk fields in every 50 transfers, and report results to the unit safety meeting.
Results
The tool change went live in the third week, and the fall-risk field now refuses to save with its default value. Ibrahim received a reassessment on arrival at the unit, and the consultant review was moved to the first slot of the morning list. Over the following quarter, the audit recorded missing risk fields in 7 of 60 transfers, down from 19 of 58 in the baseline month. The most common remaining gap was the pending-review line, which was free text and easy to overlook. The unit safety meeting agreed to keep the audit running for another quarter.
Questions for discussion
- Which fields in your own handover tool can currently be saved with a default value, and who would notice if one were left unchanged?
- When a verbal summary and the written record disagree, what should the receiving nurse do before accepting responsibility for the patient?
- How would you weigh a forcing function against the workload it adds to the sending nurse at the end of a busy shift?
Case Study 3
Follow-up calls for a stretched discharge service
Tamarack Lake Health Partners, a network of four community clinics that runs a telephone follow-up service for patients leaving two hospitals
The situation
The telephone follow-up service at Tamarack Lake Health Partners aims to call every patient within two working days of discharge from one of the network's two hospitals. Four nurses handle the calls, and one post has been vacant for eleven weeks. Over the same period, weekly discharge referrals rose from 410 to 575, largely because a neighboring ward began sending patients home earlier. The discharge summaries that arrive with each patient are inconsistent. About one in five is missing a follow-up plan, and the call list is currently built in order of discharge date, which means a patient discharged with unresolved questions can wait behind someone with a routine check.
The challenge
Sadia, the service lead, has about 575 referrals a week to place into the capacity of four nurses, and the team cannot call everyone within the target without skipping some reviews. The decision is how to order the list, whether to add a summary-reading step before each call, and whether to ask the hospitals to resend incomplete summaries. Each option moves the risk somewhere else, and she has to explain the trade-off to the clinic leads.
Analysis
The clinical evidence in a discharge summary is uneven, and the service needs a quick way to read it. Patients most at risk after leaving hospital are usually those with several changes to their care at once, or a follow-up appointment that depends on a result not yet available. Those features can be picked out of a summary if the nurse knows where to look. A simple scoring rule built from three or four such features, checked against the next call outcomes, gives the list a risk order that reflects what the records say rather than when the patient happened to leave.
Triage rules in a shared service need an owner and a review date, or they drift. The network's follow-up protocol sets a two working day target for contact but does not say what to do when the target cannot be met for every patient. Without a written rule, each nurse makes local choices, and the clinic leads hear about missed calls only when a patient complains. A workable arrangement would name the clinical lead as the person who signs off the risk criteria, give the records team a defined turnaround for re-sending incomplete summaries, and agree with the hospitals which fields must be present before a discharge is sent.
- Sort by risk Score each discharge from the summary before the call list is built.
- Schedule by need Book high-risk calls first, then routine calls within the day's capacity.
- Call and record Document what was asked, what was missed, and who needs follow-up.
- Review the rules Check each week whether the score missed patients who later returned.
Actions taken
- Build the call list from a risk score that uses three or four fields from the discharge summary, and have the clinical lead approve the criteria before the first weekly run.
- Hold a short daily huddle where the nurses agree which high-risk calls must happen that day and which can move to the next working day, with the reason recorded.
- Ask the records team to flag incomplete discharge summaries within one working day and return them to the sending ward with the missing field named, not as a general request.
- Fill the vacant post with temporary cover for six weeks, and have the covering nurse read summaries and make calls from the first day.
Results
The service adopted a risk score built from four summary fields in the third week, once the clinical lead signed off the criteria. Temporary cover was in place for six weeks. Over the following month, the share of high-risk patients contacted on the day of discharge rose from 58 percent to 81 percent, and routine calls moved to the next working day in about one in eight cases. The clinic leads agreed to keep the score under review and to check each quarter how many patients returned to hospital within a week of a call.
Questions for discussion
- What would you need to know about a discharge summary before trusting a risk score built from it, and who should check that the score is still accurate?
- When demand is greater than capacity, how do you decide which routine reviews can wait without leaving a patient unprotected?
- Which of the three agreements in this case should be written into the protocol first, and what would make a nurse feel confident applying it on a busy day?
Case Study 4
Unexplained gaps in returns across community units
Brightwater Medical Group, a seven-site provider that includes two community inpatient units and a central records office
The situation
The quality team at Brightwater Medical Group reviews anonymized indicators each quarter for its two community inpatient units and five outpatient sites. Over the last two quarters, unplanned returns within 30 days of discharge varied widely between units, from 6 percent at one site to 19 percent at another, although case mix looked similar. Discharge summary completeness also varied, with some summaries missing a follow-up plan in about a third of cases and others almost never. Staff at the higher-return unit reported that they were busy, but no one could say which steps differed in practice. The indicator dashboard had been built for reporting rather than for tracing causes.
The challenge
Marisol, the clinical quality lead, has one quarter to design a change that can be monitored, and a budget that covers only a few hours of staff time per site each week. She needs to decide which causes to test first, who should own each change, and which indicator will show whether the change worked without rewarding a simple shift in documentation habits. The answer has to be defensible to the unit leads, who will be asked about it at the next review.
Analysis
Return rates are a blunt measure. A patient who comes back within 30 days may have needed to, and a low rate can hide patients who left with unresolved needs and never returned. Read against the anonymized records, the higher-rate unit discharged more patients who lived alone and more who were waiting for an appointment that had not yet been booked. Those are needs the team can act on, but only if the indicator is split by discharge plan. The evidence on what helped these patients is thin, so the review should ask whether the plan existed and reached the patient.
Process causes are easier to find when the team walks the discharge path with the people who use it. Here the summary is written by the ward doctor, completed by a clerk, and sent electronically to community teams. At the higher-return unit, the follow-up field had moved lower on the screen during a recent update, and clerks skipped it when the ward was busy. The protocol requires a completed follow-up plan before transfer but names no owner for checking it. A monitored cycle needs one named owner for each step, a few process measures beside the return rate, and a fixed date for deciding whether the change should stay.
Actions taken
- Split the return indicator by discharge plan status and by whether the follow-up appointment was booked before transfer, reported monthly for each unit.
- Move the follow-up field back to its original position on the template and add a required-field check that stops the summary from being sent with the field empty.
- Assign the unit's senior clerk to check the sent summaries each afternoon, using a one-page list of discharges and the plan status recorded for each one.
- Run the cycle for two quarters with a review at the end of each month, and decide at the second quarter whether to keep, adjust or drop the change based on process measures.
Results
The template change and the afternoon check went live in the third week. In the first full month, the higher-return unit recorded follow-up plans in 94 of 100 summaries, up from 61 of 100 before the change. The group was careful with that result, since one month is short and winter patterns can move numbers. The indicator was split as planned, and the quarter review showed that most of the gap between units came from appointments booked after transfer, not from missing summaries. The steering group kept the change and extended the split indicator to all seven sites.
Questions for discussion
- Which anonymized indicators would you split first to test whether a difference between units reflects care, case mix, or the way records are completed?
- Who in your service should own the check that a process step actually happened, and how do you keep that person from becoming the only safeguard?
- What would convince you that a monitored change should be dropped, and how would you agree that threshold with the people who work the process?
Case Study 5
A confidentiality request from a son with paperwork
Juniper Crossing Care Services, a home and community care provider with fourteen clinical staff and a shared electronic record
The situation
Aurelio, a 74-year-old patient receiving community care for a long-term condition, has a record that includes a written instruction from two months ago asking staff not to share the detail of his test results with his son, Kwame. Kwame calls the team most days, has taken over much of the shopping and transport, and recently presented a document he described as a power of attorney. The document was signed years ago, names Kwame for finance only, and says nothing about health decisions. Aurelio, when asked in the third week, said he was glad Kwame was involved but did not want to be told everything about his results.
The challenge
Beatriz, the care coordinator, has to decide what Kwame can be told today, whether the team should ask Aurelio directly about the instruction, and whether the ethics advisor needs to be involved before the next visit. She also has to make sure the record reflects what Aurelio actually said, not what the family assumes, and that the team does not discuss his care in front of Kwame without his agreement.
Analysis
Aurelio's needs have two parts that can pull apart: his wish for privacy about detail, and his wish to keep his son close. Both are legitimate, and the record should not treat one as a mistake. The clinical evidence is mostly about his daily function and results, while what he wants shared is a matter of his own preferences. The power of attorney document matters only as far as it applies, and at present it does not give Kwame a say in health decisions. Until the team confirms Aurelio's current wishes directly, the most reliable evidence is what he said in the third week, recorded in his own words.
Consent and confidentiality in community services rest on the patient's own wishes and capacity, not on whether a family member holds a form. The service's protocol says a patient's documented preferences take precedence over general requests, and it sends unclear cases to the clinical ethics advisor. That routing is sensible, but it only works if the coordinator knows when a case counts as unclear. The first step is to ask Aurelio directly, with Kwame absent if he agrees, what he wants shared. If it remains uncertain, the ethics advisor should review the record and the document together, and the outcome should go into the care plan.
Actions taken
- Confirm Aurelio's current wishes in a private conversation, record his answers in his own words, and date the entry so the next visit can check whether the instruction still stands.
- Ask the ethics advisor to review the power of attorney document against the local legal guidance on what it covers, and write the answer into the record in plain terms.
- Agree a short script for telephone calls from family members that confirms what staff can and cannot discuss, and use it for every caller, not only this one.
- Hold a short team discussion each week about any patient whose consent or information rules are unclear, so that decisions are shared and not left to a single coordinator.
Results
Aurelio confirmed in a private conversation that he wanted Kwame to hear about appointments and general progress but not the detail of his results, and he asked that the record say so in those words. The ethics advisor reviewed the document and advised that it covered finance only, which the team recorded and shared with Kwame in a short letter. Kwame was disappointed but accepted the explanation, and he continued to help with transport. The team's weekly discussion has since handled two similar cases, each with a written decision in the care plan.
Questions for discussion
- What would you need to hear from Aurelio before you were comfortable sharing any detail with Kwame, and how would you record that answer so it stays current?
- When a family member holds paperwork that looks official but does not cover health decisions, how should the team explain the gap without weakening trust?
- How does a team decide when a consent question has become complex enough to route to an ethics advisor, and what should wait until the next weekly discussion instead?
Learning Resources
Healthcare CASE STUDIES
China, India, United States, Indonesia, Pakistan, Nigeria, Brazil, Bangladesh, Russia, Japan, Mexico, Philippines, Vietnam, Egypt, Turkey, Germany, United Kingdom, France, Italy, Canada, South Korea, Australia, Spain.