How should an error in a client's record be corrected?

How should an error in a client's record be corrected?

• A. Delete the incorrect information entirely
• B. Cross out the incorrect info and write the correct information with no signature
• C. Draw a single line through the incorrect information and add an addendum
• D. Leave the record as is, since it is not a legal document

Answer: (C)

The process of correcting an error in a client's record is crucial to maintaining the integrity and accuracy of the clinical documentation. Drawing a single line through the incorrect information while adding an addendum is the proper method for correction because it preserves the original content while clearly indicating what was incorrect. This approach ensures transparency and accountability in record-keeping. By striking through the incorrect information, it shows that a change has been made without erasing the original entry, which could create confusion about whether the information was ever recorded. Adding an addendum provides clear context regarding the correction, including the correct information and any relevant details, as well as the clinician’s signature and date to validate the change. This practice aligns with ethical standards and legal guidelines in clinical documentation. Moreover, this method protects both the client and the clinician by keeping a clear record of what was said and done, which is important for continuity of care and legal protection should any disputes arise. This method strikes an appropriate balance between confidentiality, accountability, and clarity in health records.

The process of correcting an error in a client's record is crucial to maintaining the integrity and accuracy of the clinical documentation. Drawing a single line through the incorrect information while adding an addendum is the proper method for correction because it preserves the original content while clearly indicating what was incorrect.

This approach ensures transparency and accountability in record-keeping. By striking through the incorrect information, it shows that a change has been made without erasing the original entry, which could create confusion about whether the information was ever recorded. Adding an addendum provides clear context regarding the correction, including the correct information and any relevant details, as well as the clinician’s signature and date to validate the change. This practice aligns with ethical standards and legal guidelines in clinical documentation.

Moreover, this method protects both the client and the clinician by keeping a clear record of what was said and done, which is important for continuity of care and legal protection should any disputes arise. This method strikes an appropriate balance between confidentiality, accountability, and clarity in health records.