What should you do if you make an error in a medical chart?

When an error is made in a medical chart, the appropriate action is to strike through the error and initial it. This method maintains the integrity of the medical record by allowing the original entry to remain visible, which is vital for accuracy and accountability. Striking through indicates that the information is incorrect, while initialing helps to document who made the correction, providing a clear audit trail.

Using white-out to cover the error would compromise the authenticity of the medical record, potentially leading to serious legal and ethical issues. Rewriting the entire chart can also create confusion and may obscure the original information that is critical for continuity of care. Leaving the error uncorrected allows incorrect information to remain in the patient’s medical record, which could result in inappropriate treatment or misunderstanding of the patient’s medical history. Thus, properly correcting the record by striking through and initialing is the correct procedure.