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If you make an error documenting in the medical record, should you cover it up with correction fluid or scribble through the mistaken entry?

Hand

True

Standard

False

The correct response highlights the importance of maintaining the integrity of medical records. In professional healthcare practice, it's crucial to correct documentation errors properly to ensure clarity and accuracy. Instead of using correction fluid or scribbling through an entry, which can obscure important information and create confusion, the appropriate action is to draw a single line through the error. Then, the correct information should be added nearby, accompanied by the date and your initials. This method preserves the original entry for reference and demonstrates transparency in record-keeping. Following proper protocols helps maintain trust in the medical record and aligns with best practices in healthcare documentation.

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