What should you do if a client wants corrections made to a note from a consulting physician?

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The correct choice underscores the importance of maintaining the integrity of medical records while allowing for transparency in patient care. When a client requests changes to a note made by a consulting physician, it is crucial to recognize that each healthcare provider's documentation is their professional responsibility and must remain unaltered. Changing someone else's notes could lead to confusion or misrepresentation of the patient's care and treatment history.

Instead of modifying the physician’s original note, the best course of action is to document the patient's concerns or perceptions in your own note. This practice preserves the integrity of the original records while ensuring that the client’s voice and any relevant information they wish to convey are appropriately acknowledged. This approach is compliant with legal and ethical standards governing health records, ensuring you respect the autonomy of the consulting physician’s documentation while also maintaining clear communication.

This choice aligns with best practices in healthcare documentation, which emphasize accuracy, accountability, and clarity in maintaining patient records.

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