HESI General Chairside Assisting Practice Exam

What is the proper way to make a correction on a patient's record?

1. White-out the error

2. Use pencil to draw a single line through the entry, initial, and date

3. Write over the incorrect entry with a new date

4. Erase the mistake

The correct answer is: Use pencil to draw a single line through the entry, initial, and date

Making a correction on a patient's record is a critical procedure that ensures the integrity and accuracy of the medical documentation. The recommended approach involves drawing a single line through the incorrect entry, followed by the individual's initials and the date. This method maintains the original entry while clearly indicating that a correction has been made. It provides an auditable trail that shows what was changed and when, which is essential for legal and ethical standards in patient documentation. Using white-out can obscure the original information entirely, potentially creating issues with transparency and accountability. Writing over the incorrect entry without proper notation can cause confusion and lead to misinterpretation of the data. Erasing a mistake may leave no record of what was initially documented, which is not acceptable in maintaining accurate patient records. Maintaining visibility of the original entry with a clear indication of the correction aligns with best practices in healthcare documentation.