Question

A man comes to the emergency department after a stab wound. Your notes document a $500-\mathrm{mL}$ loss of blood. Later that night the patient develops asystole and dies. You find the loss of blood was originally really $3,000 \mathrm{~mL}$, which was not recorded by you. What should you do to correct the documentation? a. Use correction fluid to eliminate the original note. b. Erase the original note. c. Remove the original note from the chart. d. Write a new note timing and dating it at the same time as the original note. e. Write a new note with the current date and time.

   A man comes to the emergency department after a stab wound. Your notes document a $500-\mathrm{mL}$ loss of blood. Later that night the patient develops asystole and dies. You find the loss of blood was originally really $3,000 \mathrm{~mL}$, which was not recorded by you.
What should you do to correct the documentation?
a. Use correction fluid to eliminate the original note.
b. Erase the original note.
c. Remove the original note from the chart.
d. Write a new note timing and dating it at the same time as the original note.
e. Write a new note with the current date and time.
Show more…
Medical Ethics for the Boards
Medical Ethics for the Boards
Conrad Fischer 3rd Edition
Chapter 1, Problem 58 ↓

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Step 1

Recognize that the original note recorded a loss of $500 \mathrm{~mL}$ instead of the actual $3,000 \mathrm{~mL}$.  Show more…

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A man comes to the emergency department after a stab wound. Your notes document a $500-\mathrm{mL}$ loss of blood. Later that night the patient develops asystole and dies. You find the loss of blood was originally really $3,000 \mathrm{~mL}$, which was not recorded by you. What should you do to correct the documentation? a. Use correction fluid to eliminate the original note. b. Erase the original note. c. Remove the original note from the chart. d. Write a new note timing and dating it at the same time as the original note. e. Write a new note with the current date and time.
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