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《Chinese Medical Record》 2012-03
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A Discussion on Correction Mode of Writing Defects of Medical Records

Li Tian,Bi Yuqing,Chen Li,Beijing Tiantan Hospital Affiliated to Capital Medical University,Beijing 100050,China  
This paper discusses several modes about writing defects of medical records for avoiding legal issue because of correction of writing defects of medical records.At present,there are several modes of correction: first,using double lineation above wrong writing;second,deleting original record in computer and rewriting,to preserve or not to preserve modification mark in system;third,to modify on paper-based medical records and re-copying out with discarding the original record.These modes have drawbacks such as untidy page or without original record after modification;especially the latter may easily causes legal issue.As for writing defects or mistakenness of correction,we can use correction explanation to explain the original problem and the correct content.This mode not only maintain the tidiness of medical records page,but also without discarding the original medical record,the most important is not easily causing tangle because of defects correction.
【CateGory Index】: R197.3
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