NCLEX · Documentation and Reporting

An error is made in documenting on a paper chart. What is the correct procedure to correct it?

Correct answer

Draw a single line through the error so it remains readable, write 'error' or 'mistaken entry' above it, initial and date the correction, then write the correct entry

  1. A Erase the error
  2. B Draw a single line through the error so it remains readable, write 'error' or 'mistaken entry' above it, initial and date the correction, then write the correct entry
  3. C Use white-out to cover the error
  4. D Tear out the page

Why this is the answer

Paper chart corrections follow specific legal procedures because the chart is a legal document. Correct method: (1) Single line through the error — DO NOT scribble out, erase, or use white-out; the original entry must remain readable; (2) Write 'error,' 'mistaken entry,' or 'wrong patient' near the lined-out entry; (3) Initial and date the correction; (4) Write the correct entry. Why readable: in legal proceedings, alterations that obscure the original raise questions about tampering and fraud. White-out, scribbling out, tearing pages, or any obliteration looks like cover-up and can severely damage credibility. Electronic charts: most EHRs allow corrections through a specific edit function that retains the original entry as an audit trail — never delete entries, use the correction feature. Late entries: when documenting after the fact, mark as 'late entry,' include current date/time of documentation AND the original date/time of the event ('Late entry: 6/15 1500 documenting care provided 6/14 0900...'). Never document care before performing it ('forward charting' is fraud). Never document for another person. Never share login credentials in electronic systems. The chart is a contemporaneous record of care and the primary defense in malpractice litigation — chart as if you'll defend each entry in court.
Source: NCSBN NCLEX-PN, Chart Corrections

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