Patient Safety & LawQuestion 87 of 100

An assistant writes the wrong tooth number in a paper chart entry. What is the correct way to fix it?

a.Cover the error with correction fluid and write the correct number over it
b.Draw a single line through the error, write the correction, and add initials and the date
c.Erase the entry completely and rewrite the note
d.Tear out the page and start a new chart

Explanation

A single line through the error with the correction, initials, and date preserves the original entry and shows who changed it and when, which keeps the record legally defensible. Correction fluid, erasing, and removing pages obliterate the original entry and can be interpreted as falsifying a legal document. The chart is a legal record, so nothing in it may be destroyed or hidden.

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