layout.fixed.naaccr.doc.naaccr12.textDxProcXRayScan.html Maven / Gradle / Ivy
Alternate Name
Item#
Length
Source of Standard
Column #
2530
1000
NPCR
6565-7564
Description
Text area for manual documentation from all X-rays, scan, and/or other imaging examinations that provide information about staging.
Rationale
Text documentation is an essential component of a complete electronic abstract and is heavily utilized for quality control and special studies. Text is needed to justify coded values and to document supplemental information not transmitted within coded values. High-quality text documentation facilitates consolidation of information from multiple reporting sources at the central registry.
The text field must contain a description that has been entered by the abstractor independently from the code(s). If cancer abstraction software generates text automatically from codes, the text cannot be utilized to check coded values. Information documenting the disease process should be entered manually from the medical record and should not be generated electronically from coded values.
Instructions
- Prioritize entered information in the order of the fields listed below.
- Text automatically generated from coded data is not acceptable.
- NAACCR-approved abbreviations should be utilized (see Appendix G).
- Do not repeat information from other text fields.
- Additional comments can be continued in empty text fields, including Remarks. For text documentation that is continued from one text field to another, use asterisks or other symbols to indicate the connection with preceding text.
- If information is missing from the record, state that it is missing.
- Do not include irrelevant information.
- Do not include information that the registry is not authorized to collect.
Note: For abstracting software that allows unlimited text, NAACCR recommends that the software indicate to the abstractor the portion of the text that will be transmitted to the central registry.
Suggestions for text:
- Date(s) and type(s) of X-ray/Scan(s)
- Primary site
- Histology (if given)
- Tumor location
- Tumor size
- Lymph nodes
- Record positive and negative clinical findings. Record positive results first
- Distant disease or metastasis
Data Item(s) to be verified/validated using the text entered in this field
After manual entry of the text field, ensure that the text entered both agrees with the coded values and clearly justifies the selected codes in the following fields:
Item name
Item number
Date of Diagnosis
390
RxSumm--Dx/Stg Proc
1350
Primary Site
400
Laterality
410
Histology (92-00) ICD-O-2
420
Histology ICD-O-3
522
Collaborative Stage variables
2800-2930
SEER Summary Stage 1977
760
SEER Summary Stage 2000
759