If you realize you forgot to document a blood glucose check before a patient signed a refusal form, what should you do?

When a critical piece of information, such as a blood glucose check, is omitted from a patient's report, it is essential to maintain accurate and complete documentation. Adding an addendum to the report with the correct information ensures that the medical record reflects the true state of the patient's condition at the time of care.

This approach not only corrects the documentation without disrupting continuity of care but also upholds the integrity of the record. An addendum serves as a formal way to amend the report while keeping all information transparent and accessible for any future providers who may interact with the patient. This practice is essential in medical documentation as it helps prevent misunderstandings regarding the patient's medical history and treatment decisions.

In contrast, simply disregarding the mistake would leave the record incomplete and possibly lead to adverse outcomes, while informing a supervisor is an important step, it primarily addresses accountability rather than rectifying the documentation itself. Returning to the patient for re-signing is not practical, especially after they have already refused care, and it can lead to unnecessary confusion or distress for the patient. Thus, the process of correcting the documentation with an addendum is both the most professional and practical solution.