If a written error occurs in the patient record what is the legal protocol?

Answer 1

If a written error occurs in a patient record, the legal protocol typically involves drawing a single line through the error, initialing it, and writing the correct information nearby. This ensures that the original entry remains legible while the correction is properly documented. It's important to avoid erasing or using correction fluid, as this can raise suspicions of tampering. Additionally, healthcare providers should follow their facility's specific policies regarding documentation and record-keeping.