Question

What should you do if you make a mistake in charting patient information?

1) Start another chart
2) Use white-out over the error
3) Have the supervising nurse write in a correction
4) Draw a single line in blue or black ink through the error, label it 'error,' and initial the mistake

Answer 1

When charting errors occur, correct them by crossing out the error with a single line, labeling it as an error, and initialing it; never use white-out or start a new chart.

Step-by-step explanation:

If you make a mistake in charting patient information, the correct action to take is option 4: Draw a single line in blue or black ink through the error, label it 'error,' and initial the mistake. Using white-out or starting a new chart is not acceptable because it does not preserve the integrity of the medical record. Having a supervising nurse write in a correction is not standard practice; the person who made the error should correct it. After making the correction, it's essential to ensure that the patient's chart accurately reflects the patient's status, including the correct name of procedure, needle, sponge, and instrument counts, correct labeling of specimens with the patient's name, and to note any equipment issues.