Minnesota Dental Jurisprudence Practice Exam

When correcting a mistake in a patient record, what is the correct procedure to follow?

1. Erase the mistake

2. Use white out to remove the mistake

3. Place a single line through the mistake

4. Write in pencil

The correct answer is: Place a single line through the mistake

The correct procedure for correcting a mistake in a patient record is to place a single line through the mistake. This method is important because it allows for the original entry to remain visible, maintaining the integrity of the medical record. By simply striking through the error, the healthcare provider ensures that there is a clear and permanent record of what was documented, which is crucial for maintaining transparency and accountability in patient care. This practice aligns with the legal and ethical standards that govern medical records, ensuring that corrections are made in a way that does not mislead anyone reviewing the records later. It helps preserve the chronological order of events and provides a basis for understanding changes made during a patient's treatment. By comparison, erasing the mistake or using white-out can significantly obscure the original documentation, which could lead to potential misunderstandings or even legal issues if the alteration is not clear. Similarly, writing in pencil undermines the permanence and reliability of the record, as pencil can be easily erased or altered, compromising the record’s integrity. Thus, striking through the mistake is the best practice in maintaining accurate, trustworthy health records.