What action should you take if you discover an error in a patient record after signing and dating an entry?

• A. Delete the entry
• B. Re-sign with different date
• C. Immediately document the correction with an audit note and initials, maintain original entry
• D. Do nothing

Answer: (C)

Maintaining the integrity and traceability of patient records is essential. If you discover an error after signing, you should not delete or alter the original entry. Instead, immediately document the correction with an audit note that explains what was wrong and add your initials and the current date/time. Keep the original entry visible and add a correction or addendum that links to it, creating a clear timeline and accountability.

This audit trail is crucial for patient safety, legal compliance, and continuity of care, showing exactly when the error was identified and corrected. Deleting the entry would erase history, re-signing with a different date would misrepresent when the entry was made, and doing nothing fails to address the error and could harm the patient. Follow your facility’s policy for corrections, typically including an addendum with the rationale, date, and your initials.