Regarding proper medical record documentation, which of the following statements is incorrect?

A Each entry should be dated and signed by the attending physician

B Entries must be clear, concise, and free of unnecessary blank spaces

C Alterations should be made by striking through the original text without erasing

D Confidentiality of the medical record must always be maintained

Solution

Correct Answer: Option B

- The statement "Entries must be clear, concise, and free of unnecessary blank spaces" is incorrect because medical records should avoid completely eliminating blank spaces, as leaving some space can prevent unauthorized additions later and maintain record integrity.
- Proper documentation requires clear, concise entries dated and signed by the physician, and alterations must be made by striking through errors without erasing to preserve transparency.
- Maintaining confidentiality is mandatory to protect patient privacy.

Reference: Bates' Guide to Physical Examination and History Taking, 13th Edition, Chapter 2: Medical Records, p. 30-32

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