How should errors in a medical record be handled?

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Handling errors in a medical record is critical to maintaining the integrity and accuracy of patient information. The correct approach is to document errors with correction notes. This method ensures that the original entry remains intact, preserving the accuracy of the medical history and treatment decisions while clearly indicating that a correction has been made.

By documenting the correction, healthcare providers maintain transparency and accountability. Correction notes typically indicate who made the correction, when it was made, and what the correction entails. This practice helps avoid misunderstandings or confusion regarding the patient's care and ensures that an accurate, complete permanent record is maintained.

The other options, such as obliterating or crossing out entries, compromise the original data and can lead to misinterpretations in the patient’s medical history. Leaving errors as is can lead to confusion and inconsistencies in patient care. Hence, documenting corrections with notes is the appropriate and professional standard for managing errors in medical records.

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