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.