How should a healthcare worker correct an error in patient documentation?

Proper Error Correction Procedure

1. Draw line through entry (thin pen line). Make sure that the inaccurate information is still legible.
2. Initial and date the entry.
3. State the reason for the error (i.e. in the margin or above the note if room).
4. Document the correct information.

How do you respond to a medical error?

Five Ways to Respond to a Medical Mistake

1. Acknowledge your mistake to the patient or family.
2. Discuss the situation with a trusted colleague.
3. Seek professional advice.
4. Review your successes and accomplishments in medicine.
5. Don’t forget basic self-care.

How do you apologize after a medical error?

Get the facts. Don’t simply react with emotion or guilt. If an apology is, indeed, warranted, make sure that it is sincere. Acknowledge the error, give the patient an explanation of what happened, express your remorse that it happened, and outline what steps you will take to make reparation.

What are the basic purposes of written patient records?

Purposes of Patient Records

• Patient Care. Patient records provide the documented basis for planning patient care and treatment.
• Communication.
• Legal documentation.
• Billing and reimbursement.
• Research and quality management.

How do you think you would react if you make an error that caused harm to a patient?

Explain—Provide an explanation of why the error occurred. Apologize—When appropriate, provide an apology. Communicate—Share how the health impact will be minimized and explain how the event will impact the patient’s future care.

How do I admit a medical mistake?

The first step toward taking responsibility for a medical mistake is letting a patient know what happened and why. Apologize. Although an apology can’t change what happened, patients deserve a sincere apology when the provider they’ve trusted with their health makes a mistake. Compensate.

Would and Should you disclose if an error occurred to a patient?

It is generally agreed that harmful errors must be disclosed to patients, although it is unclear what the true frequency is for disclosing these adverse events. When minimally harmful events or near misses occur, research indicates that physicians are less inclined to disclose it.

How do you say sorry to a patient?

A well-structured, conversational apology might sound like this: I and our organization feel responsible for what has happened, and I want to restore to you the support you deserve. [Acknowledgement] Let me tell you what I know happened, without speculation, and I promise to report more to you as it becomes known.