What should you do if a mistake is made when recording in a medical record?

When a mistake is made in a medical record, the proper course of action is to place a single line through the error, correct it, and initial it. This practice is crucial for maintaining the integrity and accuracy of medical records.

By crossing out the error with a single line, it clearly indicates that there was a mistake, while still allowing anyone reviewing the record to see what the original entry was. This transparency is important in legal and medical contexts, where complete accuracy and traceability of information are paramount. Initialing the change serves to authenticate the correction and shows accountability for the amendment.

The overall aim is to ensure that the record remains accurate and reliable, which is essential for ongoing patient care and for any legal considerations that may arise regarding medical records. This approach adheres to the ethical and professional standards expected in veterinary practice and supports effective communication among veterinary staff.