Everyone makes mistakes. It is a fact of living life as a human being.
As a clinician, if you treat enough people, and so you create enough records and notes, you’re going to put something in a treatment record that doesn’t belong there.
Now what?
As you can imagine, there are rules related to how to fix an error when you make one in a treatment record.
It is important to remember, do not delete or blackout the original information. The original entry needs to still be still visible and legible, even if you made the mistake of documenting content into the wrong record. So, draw a single line through the original entry. In the electronic health record, using the “strikethrough” font style will accomplish this.
DO NOT alter the original entry. If you are changing a word, or editing a sentence, the original text must be visible along with the edits.
If you are still using handwritten records, make sure to initial (or first initial and last name) and date each change to the record, and identify as a “mistaken entry”. Most electronic health records have an ability to update records, so entries should be date, author, and time stamped, and there should be a symbol identifying the new or additional information. In either case, identify the reason for the correction.