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When recording in the medical records, you do the following except

a. use ink
b. make sure the writing is readable
c. use correction fluid or erase when you make a mistake
d. record only what you did and observed

1 Answer

1 vote

Final answer:

In medical record keeping, correction fluid or erasing is not used when an error is made. A mistake should be crossed out with a single line, and the correct information should be noted nearby. Proper practice also involves using ink, ensuring readability, and accurately documenting actions and observations. so, option c is the correct answer.

Step-by-step explanation:

When recording in medical records, all actions should be documented with precision and care, except for using correction fluid or erasing mistakes. Instead, if a mistake is made, it should be struck through with a single line so that it remains legible, and the correct information should be added alongside it, often with the current date, time, and the initials of the person making the correction. This practice ensures the integrity of the record. Additionally, it is important to use ink, make sure the writing is readable, and record only what you have directly seen or done to provide clear and accurate documentation.

Good medical records should include clear and readable writing, accurate logging of procedures, and relevant observations without any use of correction fluid. These actions are critical for maintaining the legal and clinical accuracy of the records. All documentation in medical records is a legal document and must be treated as such for the safety and protection of both healthcare professionals and patients.

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