Communication and Veterinary Professional Support ServicesDifficulty 3/5
An error is discovered in a medical record written yesterday. How should it be corrected?
- ARemove the page and rewrite it in full with the corrected information
- BLeave the error and note the correction verbally at the next handover
- COverwrite the incorrect entry so the record reads accurately from now on
- DAdd a dated, signed amendment that leaves the original entry legible
Show answer and rationale
Correct: D. Medical records are legal documents. Corrections are made by a dated, signed amendment with the original entry still legible; obliterating or replacing entries destroys the record's integrity.
- C — Overwriting destroys the original entry and undermines the record.
- A — Replacing a page removes evidence of what was recorded.
- B — A verbal note leaves the written record wrong.