What should you do if you make a mistake in a medical record?

When you make a mistake in a medical record, the appropriate action is to draw a straight line through the error and write 'mistaken entry' above it. This method maintains the integrity of the medical record while accurately documenting the mistake. It allows anyone reviewing the record to see what the original entry was, acknowledge the error, and understand that it has been corrected in accordance with proper protocols. This practice is critical because medical records must be accurate and complete for optimal patient care and legal documentation.

Choosing to erase the mistake completely can lead to confusion and may be seen as tampering with important documentation. Leaving the mistake as is could result in miscommunication regarding a patient's care and treatment. Informing the patient immediately may not be appropriate unless the error directly impacts their treatment; the primary focus should instead be on correcting the record in a professional and standardized manner.