What is the proper method of correcting errors in a paper medical record?

Question:

Dear Nancy,

I was taught to correct a charting error by drawing one line through the error, initialing it, and rewriting. I was also told not to use Wite-Out. Is there any place that defines this more? Is it a law? What can happen to a nurse who uses Wite-Out and writes over it or crosses words out with multiple lines? I am a director of operations and have one nurse who uses Wite-Out and writes over, especially dates, so I don’t know what the original date was. Can you direct me to where I can learn more so I have something to back me when I approach this nurse with these issues?

Mariska

Nancy Brent replies:

Dear Mariska,

Your understanding of how to correct errors is indeed accurate. The use of Wite-Out and then writing over the dried Wite-Out raises many questions legally, not the least of which is the one you raised: What was in the original documentation?

There are many excellent texts on legal issues in documentation. You can identify them by placing “documentation in the medical record” in your browser’s search bar and then reviewing the results. In addition, there are many state and federal laws that govern documentation in the medical record and what is required for entries, corrections, etc. Some of those laws include The Health Care Insurance Portability and Accountability Act (federal) and The Medicare and Medicaid Statute (federal). State laws include rules for licensure of healthcare facilities and nurse practice acts. Private accreditation agencies also mandate documentation requirements.

It may be helpful for you to consult with a nurse attorney or attorney in your state who can provide an in-service on the principles of good documentation and how suspicious corrections or additions to a record may result in liability for the hospital and those involved if there is a patient injury or death (professional negligence suit), questionable billing practices (fraud and abuse), or false documentation to cover a particular patient situation.

At a minimum, your risk manager should be alerted to this problem so that he or she can begin an in-house review of records and institute better policies to eradicate this practice. If the policies governing documentation are not followed, the nurse manager should be able to initiate disciplinary action against those employees who continue to violate established documentation policies.

Cordially,
Nancy

Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.