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What is the proper technique for making corrections in a medical record to maintain accuracy and legality?

A) Erase the incorrect information and rewrite it.
B) Use whiteout to cover the error and write over it.
C) Draw a single line through the error, date, and initial the correction.
D) Ignore the error as it's not legally significant.

1 Answer

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Final answer:

The correct method for making corrections in a medical record is to draw a single line through the error, then date and initial the correction to provide clear accountability and maintain legal standards. Option C is correct.

Step-by-step explanation:

The correct method for making corrections in a medical record to uphold accuracy and legality is option C) Drawing a single line through the error, dating the correction, and initialing it. This approach is essential for maintaining the legibility of the original content, a crucial aspect from a legal perspective, and it establishes a transparent record of the modification, including who made it and when. This meticulous correction technique ensures clarity and accountability.

Contrarily, employing methods like erasing, using whiteout, or simply overlooking the error is inappropriate. These approaches can be construed as attempts to conceal information, raising ethical and legal concerns. Furthermore, such practices may lead to confusion and the introduction of additional inaccuracies into patient records, compromising the integrity of the medical documentation.

By adhering to the proper correction method—drawing a single line, dating, and initialing—the medical record not only retains its accuracy but also upholds transparency and accountability in healthcare documentation. This meticulous approach aligns with legal standards, ensuring that healthcare professionals maintain the highest standards of integrity and precision in managing patient records.

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