Question

How do you correct medical records both electronically and manually?

a) Use correction fluid for both
b) Use an eraser for both
c) Use a single line through errors for both
d) Use white-out for both

Answer 1

To correct medical records, you must use a single line through errors for both manual and electronic records, ensuring the original information remains visible. Manual corrections are initialed and dated, while electronic systems track changes for audit purposes. Option c is the answer.

Step-by-step explanation:

When correcting medical records, it is essential to preserve the integrity and accuracy of the records while adhering to proper protocols. The correct option is c) Use a single line through errors for both. Here is how it's typically done:

• For manual corrections, draw a single line through the incorrect information so that it is still legible. Write the correct information near the mistake, and then initial and date the change.
• For electronic corrections, most systems will have a method for making corrections that includes an audit trail. This usually involves entering the corrected information and providing a reason for the change. The original entry is retained in the system for legal and audit purposes.

It is not acceptable to use correction fluid, white-out, or erasers in medical records because these materials obscure the original entry and therefore cannot be audited. Professional standards and legal requirements often dictate the process of correcting records, and following them is crucial for patient care and legal compliance.