How should corrections to errors in a paper health record be documented?

To properly document corrections to errors in a paper health record, the appropriate method involves drawing a line through the error and adding a note. This practice ensures that the original entry remains visible, preserving the integrity of the record and providing a clear audit trail. Such documentation is essential in healthcare settings to maintain transparency and accountability.

When a correction is made in this manner, it allows others reviewing the record to understand what the original information was and that it has been amended. Adding a note also provides context about the correction, explaining what the error was and the reason for the change, which enhances clarity and reduces the risk of misunderstandings.

This approach aligns with best practices in health information management, emphasizing accuracy and traceability while preventing alterations that can obscure the record’s history. It reflects compliance with legal and regulatory standards governing health information documentation, ensuring that the modifications are appropriately handled and that the integrity of the medical record is upheld.