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What is the current standard for crossing out an entry on a patient’s medical record?

Monday August 10, 2009
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Question:

Dear Nancy,

What is the current accepted standard for crossing out an entry? I learned from a CLNC program that you are supposed to cross out the entry and write your initials and the date instead of writing the word “error” and your initials.

Mary Ann



Nancy Brent replies:

Dear Mary Ann,

The information you obtained from a CLNC program is certainly accurate information and consistent with how to deal with an entry that must be corrected. The purpose of doing the correction as described is to ensure that the reader sees that the correction was done in an honest manner and that the person doing the correcting is taking responsibility for the correction and when it was done.

Many believe that also writing “error” to a correction draws unnecessary attention to the correction. If there was an error in the true sense (e.g., a medication error), a careful review of the medical record will indicate this without the help of drawing a reviewer’s attention to it.

In either case, it is important for a nurse to follow his or her facility’s policy concerning corrections in the medical record in order to comply with the policy should a question arise about the correction and how it was handled in a lawsuit.

Cordially,
Nancy




Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.