What is proper protocol for correcting a paper medical record?

The proper protocol for correcting a paper medical record involves placing a single line strike through the original statement, followed by the healthcare provider's signature and the date of the revision. This method maintains the integrity of the original record while clearly indicating what has been corrected. It allows for the original information to remain legible and provides a trail of changes made, which is critical for accountability and legal purposes.

Using a strike-through also ensures that the original entry is not completely obscured, which is important for auditing and review processes. The signature and date accompanying the correction further validate the change, demonstrating who made the correction and when, which is vital for maintaining the accuracy and reliability of the medical record. This practice aligns with best practices and regulations governing documentation in healthcare, ensuring that patient information remains accurate and transparent.

The other options, such as using white-out to erase the error completely or rewriting entire sections, do not preserve the integrity of the original records and can lead to questions regarding the authenticity of the information. Initialing the correction without additional notes lacks sufficient detail, as it does not provide an adequate trail of changes or the context necessary for understanding the correction.