When correcting an error in the medical record, what is the appropriate action?

The appropriate action when correcting an error in the medical record is to cross out the error with a single line and initial it. This method maintains the integrity and accuracy of the medical record. By crossing out the error rather than erasing it, the original entry remains visible, providing a clear audit trail of the correction. Initialing the alteration also indicates who made the correction, which is essential for accountability and maintains the professionalism of the documentation.

Preserving the original entry is critical in medical records for legal and safety reasons, ensuring that anyone reviewing the record understands what information was corrected and can see the history of the documentation. This practice aligns with standard protocols in medical recordkeeping, which emphasize transparency and accuracy.