A dentist notices that last week's clinical note records the wrong tooth number. What is the most appropriate way to correct the record?

  • Correct answer

    Draw a single line through the error so it stays legible, and add a dated, initialled correction

  • Use correction fluid and rewrite the entry

  • Remove the page and rewrite the entire note

  • Leave the error and record the correct information only at the next visit

This question is one of 15 in AFK practice: Prevention, infection control and ethics. Test yourself on all of them.

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Explanations

  • Records must never be erased, obliterated or replaced. A correction should leave the original entry readable and be dated and attributed (electronic systems do this through an audit trail). Hiding the original entry could suggest that the record was tampered with.

    Source: Record-keeping guidelines of Canadian dental regulatory authorities — oneguy

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