Medication errors must be documented in the medical record with:
A) the initials of the physician in charge
B) a pen containing indelible ink
C) the signature of the individual who made the error
D) the initials of the medical office administrator
C) the signature of the individual who made the error
Medication errors must be documented in the medical record with the signature of the individual who made the error. It is not required for the physician or medical office administrator to initial the notation; what is important is that the person responsible signs the record to indicate his or her taking responsibility for the mistake. The type of ink used is not a concern.
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