How should a medication error be corrected in documentation?

Documenting a medication error requires maintaining the integrity of the medical record while also ensuring that there is a clear and accurate representation of what occurred. The correct approach involves drawing a line through the incorrect entry and then noting ‘error,’ along with the date and your initials. This method serves several important purposes: it preserves the original record, clearly indicates that an error was made, and provides an audit trail that can be referenced later if necessary.

Using correction fluid to cover the error is not appropriate, as it obscures the original documentation, making it impossible to trace or understand what was initially recorded. Rewriting the information can also lead to confusion, as it may not be clear what was changed or why. Simply deleting the incorrect entry from records eliminates important information that could be crucial for understanding patient care and accountability.

By following the correct procedure, healthcare providers can ensure accurate records while also adhering to best practices in documentation and legal requirements. This approach maintains transparency and accountability within the healthcare system.