Work through a fictional nursing home pressure injury case
This is a made-up case that shows how a nurse consultant could review a pressure injury file in Medrecords AI. The resident, the facility and every fact are invented. The steps and buttons are real. You will see the setup, the search for gaps, the wound timeline and the report, with the reviewer drawing every conclusion.
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The case
Ruth is a resident at Maple Ridge Care Center, a made-up facility. She moved in on March 4, 2024, after a hip fracture. On April 12, 2024, a nurse noted a small wound on her lower back. On May 2, 2024, she went to the hospital with a deep wound. She came back on May 9, 2024.
Dana is a legal nurse consultant. An attorney asked her to review the chart. She has the facility chart, the hospital records and the ambulance run sheet.
Step 1: Set up the case
Dana created a case and picked Nursing Home Neglect. She uploaded the files. When the case showed Needs confirming, the Confirm case details window opened.
| Field | What Dana entered |
|---|---|
| Facility | Maple Ridge Care Center |
| Admission period | March 4, 2024 to the present |
| Incident type | Pressure ulcer |
| Date of Admission | March 4, 2024 |
She pressed Add date for May 2, 2024, with the note "sent to hospital". She added May 9, 2024, with the note "back from hospital". She pressed Confirm and continue. See set up a nursing home case.
Step 2: Check what is missing
The missing records list showed 1 item: a wound clinic visit that a nurse note mentioned. Dana pressed Request from provider and sent the draft from her own email.
Then she checked each month by hand. She filtered the Documents Index 1 month at a time and searched "flowsheet". March and May had aide flowsheets. April had none. That is the month the wound started. She added a note to say so. See check whether the MDS, care plans and flowsheets are there.
Step 3: Build the wound timeline
Dana made 2 flags: "Skin" and "Care plan". On the Timeline tab, she picked Keywords and added "Braden", "stage", "wound" and "turn". She chose Any and stepped through with Date by date.
Her notes, all from the source pages:
- March 4, 2024: Braden score 14 on admission.
- March 5, 2024: care plan says turn every 2 hours.
- April 12, 2024: nurse note, small open area on the lower back.
- April 26, 2024: wound larger, dietitian not yet seen.
- May 2, 2024: ambulance run sheet and hospital note describe a deep wound.
She clicked each event to open the highlighted source page. She flagged each 1.
Step 4: Ask questions
Dana asked, "List every Braden score with its date." The answer cited 3 pages. She opened each citation and found 1 score she had missed.
She then asked, "When was the doctor told about the wound?" The answer cited a nurse note from April 14, 2024. She checked the page and added it to her notes.
Step 5: Write and check the report
In Report studio, Dana made a Nursing Home Neglect Record Review and a Standard of Care Analysis. She pressed Run Verification and Cross-Examination on each. 1 claim came back Unsupported. She fixed it by hand.
What Dana did not get from the app
- A finding of neglect. She wrote her own opinion for the attorney.
- F-tags or rules. The attorney looked those up.
- Staffing levels. The app does not pull PBJ staffing data.
- An automatic list of missed turns. She found the April gap herself.
To repeat these steps on a real file, see build pressure injury, fall and weight loss timelines. Our guide on pressure injury case records lists what to collect.
Medrecords AI organizes and cites the records. Its output is not a medical or legal opinion and does not replace your expert.
Related help
- Review a nursing home neglect case
- Choose a report for this case
- Check any fact against its source page
Facts checked against the Medrecords AI app code on 2026-10-24.