Explanation

Medical record errors are corrected through late addenda, never through deletion, overwriting, or alteration of the original entry. The integrity of the medical record depends on maintaining a complete and accurate audit trail. When a PMHNP identifies an error in a previous note, the correct procedure is to create a late addendum that clearly identifies the original entry being corrected, states what the error was, provides the correct information, includes the date and time of the correction, and is signed by the correcting clinician. The original entry must remain in the record. Deleting, backdating, or altering medical records can constitute tampering — a serious legal offense — and destroys the audit trail that protects both patients and clinicians.

Key Takeaway

Medical record errors are corrected through late addenda, never through deletion or alteration.