If corrections are made to the medical record, the correction should

If corrections are made to the medical record, the correction should

• A. Include date, time, and initials
• B. Be initialed
• C. Start over on a new page
• D. Be covered with correction fluid

Answer: (A)

Corrections in the medical record must create a clear, unbroken audit trail. When you correct an entry, you document the date and time of the correction and sign with your initials to show who made the change and when. This preserves the original note and provides accountability, so others can see both what was written and what was corrected, in the exact sequence it occurred. Using correction fluid hides or alters the original entry and is not acceptable, while starting a new page breaks the continuity of the chart and can obscure the full record. Merely initialing without date and time does not establish when the correction happened, so it fails to provide a proper audit trail.

Corrections in the medical record must create a clear, unbroken audit trail. When you correct an entry, you document the date and time of the correction and sign with your initials to show who made the change and when. This preserves the original note and provides accountability, so others can see both what was written and what was corrected, in the exact sequence it occurred. Using correction fluid hides or alters the original entry and is not acceptable, while starting a new page breaks the continuity of the chart and can obscure the full record. Merely initialing without date and time does not establish when the correction happened, so it fails to provide a proper audit trail.