Medical Records Updates

Tuesday, January 31, 2012 at 8:45:01 AM

Cancer staging forms should include a presurgical clinical stage and a postsurgical pathological stage. Critical elements of the clinical stage need to be included as well.

To correct paper medical record documentation, draw a line through the incorrect entry, document the type of error, date and initial it. The correct entry is then documented with a signature, including the date and time. With electronic documentation, incorrect medical record entries should be brought to the attention of the unit coordinator or system administrator for correction.


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