What is the proper procedure for correcting an incorrect entry in a resident's chart?

What is the proper procedure for correcting an incorrect entry in a resident's chart?

• A. Draw a line through the error and write "error" or "mistaken entry" and initial
• B. Erase the error and rewrite the correct entry
• C. Cross out the error and write the correct information above it
• D. Make a note in a separate section of the chart

Answer: (A)

The proper procedure for correcting an incorrect entry in a resident's chart involves drawing a line through the error and writing "error" or "mistaken entry," followed by your initials. This method maintains the integrity of the original documentation while clearly indicating that an error was made. It ensures that the history of the chart remains intact and can be audited, providing a clear record for other healthcare professionals reviewing the chart. Documenting the error in this manner prevents any potential confusion or misinterpretation that could arise from trying to erase or cover up the mistake. By formally acknowledging the error, you are upholding the standards of accurate and ethical record-keeping required in healthcare settings. This process aligns with legal guidelines and best practices in nursing documentation. Other options, such as erasing the error or crossing it out and writing the correction above it, compromise the integrity of the record and can lead to issues in accountability and traceability. Writing a note in a separate section of the chart does not effectively communicate the correction in the context of the original entry, which might cause confusion for those referencing the chart later.

The proper procedure for correcting an incorrect entry in a resident's chart involves drawing a line through the error and writing "error" or "mistaken entry," followed by your initials. This method maintains the integrity of the original documentation while clearly indicating that an error was made. It ensures that the history of the chart remains intact and can be audited, providing a clear record for other healthcare professionals reviewing the chart.

Documenting the error in this manner prevents any potential confusion or misinterpretation that could arise from trying to erase or cover up the mistake. By formally acknowledging the error, you are upholding the standards of accurate and ethical record-keeping required in healthcare settings. This process aligns with legal guidelines and best practices in nursing documentation.

Other options, such as erasing the error or crossing it out and writing the correction above it, compromise the integrity of the record and can lead to issues in accountability and traceability. Writing a note in a separate section of the chart does not effectively communicate the correction in the context of the original entry, which might cause confusion for those referencing the chart later.