Oklahoma PMU Practice Exam

Chart notes should be permanent, legible, and auditable. Using pencil or white-out undermines that reliability because pencil can smudge or fade and white-out hides original content, creating appearance of tampering and making the record hard to verify. In professional documentation, changes should be transparent and traceable—no erasures—often by striking a single line through the entry, noting the correction, dating/time, and initialing, or by adding an approved addendum.

Recording client vitals, documenting the service performed, and noting follow-up instructions are all appropriate and essential parts of chart notes, providing objective data, ensuring what was done is recorded, and guiding future care.