Question

What should you never do when documenting health information?

A. Be brief and concise
B. Write facts not opinions
C. Erase or use correction fluid
D. End note with your full name and title

Answer 1

Never erase or use correction fluid when documenting health information; amendments should be clearly marked. Documentation should be factual, concise, and end with the documenter's full name and title.

Step-by-step explanation:

When documenting health information, one should never erase or use correction fluid. It's crucial to maintain the integrity of the medical record, and any amendments should be clearly marked as such with a reason for the change, the date of the change, and the identity of the person making the correction. Documentation should be brief and concise to ensure clarity, and it should consist of facts, not personal opinions or assumptions. Finally, it's professional practice to end the documentation with your full name and title to validate the entry and establish responsibility.