• Document site and laterality (e.g., main bronchus, left lower lung lobe)
• Differentiate between primary and secondary (metastatic) site.
  • Document primary site and if it is still present.
  • For secondary sites, document each individual site.
• Document final pathology results. If necessary, add an addendum to the discharge summary for diagnoses added after the patient has been discharged.

Adult (main)|Pediatrics (main)

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