What happens if you make a documentation error? In the past, charting errors were corrected by writing the word “error” near the mistake. The standard today is to write “mistaken entry” above the line drawn through the words that need to be deleted. The author’s date, time, and initials go above “mistaken entry.”
Here are some more helpful hints:
- Keep the original entry intact. Never scratch out or attempt to obliterate the previous entry. It gives the perception of trying to “cover up” and could cast doubt as to the integrity of the writer and the medical record.
- Indicate late entries.
If a late entry is necessary, the writer should indicate such. For example “8/24/06 2:30 p.m. Late entry for 8/24/06 10 a.m.”- Avoid altering numbers/words.
Never try to change a word or number into the correct one you intended.
Source: Stressed Out About Your First Year of Nursing, HCPro Inc., 2006. For more information on our series of Stressed Out books, visit www.stressedoutnurses.com
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