Should you ever alter a medical record?

• A. Yes
• B. Only for typos
• C. No
• D. Only with supervisor approval

Answer: (C)

Medical records must be accurate, complete, and traceable. Altering a chart after it’s created undermines that integrity and can lead to serious legal and patient-safety consequences. Tampering with documentation can be seen as falsification and may expose you and the healthcare organization to disciplinary action, liability, and loss of trust.

If you find an error, the correct approach is to use the proper correction process—such as an addendum or late-entry—with the date, time, and your identification, while leaving the original entry intact and visible. This preserves the original record and creates a clear, auditable trail of what happened and why the correction was made. In electronic systems, rely on the built-in correction features and follow your institution’s policies. While you may consult with a supervisor on policy and ensure compliance, the act of altering the original record is not appropriate.

So, you should never alter a medical record; corrections must be documented through approved, traceable methods.