North Carolina EMT State Practice Exam

How should you correct a mistake in a medical record?

1. Erase it and rewrite the correct information

2. Mark through the mistake with one line, initial and date it

3. Ignore it and leave it uncorrected

4. Fill in the blank with the correct information

The correct answer is: Mark through the mistake with one line, initial and date it

To correct a mistake in a medical record, the best practice is to mark through the mistake with one line, initial, and date it. This approach maintains the integrity of the original record while clearly indicating the correction that has been made. It provides an auditable trail that shows what the original entry was and how it has been amended, which is essential for legal and ethical standards in healthcare documentation. This method is crucial because erasing or rewriting can create confusion and may potentially be viewed as tampering with the medical record. Similarly, ignoring the mistake leaves inaccurate information in the patient's file, which could lead to miscommunication and errors in patient care. Simply filling in the blank with the correct information does not adequately disclose the previous error and could likewise misrepresent the patient's medical history. Thus, marking through the error, initialing, and dating it serves to enhance transparency and accountability in medical records.