What should be done if errors are discovered in a medical record?

When errors are discovered in a medical record, the proper course of action is to correct the error by following the institution's policy. This is essential because accurate medical records are critical for ensuring quality patient care and maintaining legal compliance. Correction procedures usually involve documenting the error properly, indicating what the mistake was, and providing the corrected information along with the date and, in some cases, the initials of the person making the change.

Following the institution's guidelines ensures that the correction process is standardized, promoting consistency and reliability in record-keeping practices. This also protects the integrity of the medical record and reduces the risk of confusion or potential liability issues that may arise from incorrect or outdated information. Proper documentation of changes is crucial in maintaining a clear and comprehensive patient history, which is vital for ongoing medical care and legal purposes.