layout.fixed.naaccr.doc.naaccr15.textDxProcPath.html Maven / Gradle / Ivy
Alternate Name
Item #
Length
Source of Standard
Column #
2570
1000
NPCR
10565 - 11564
Description
Text area for manual documentation of information from cytology and histopathology reports.
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) of procedure(s)
- Anatomic source of specimen
- Type of tissue specimen(s)
- Tumor type and grade (include all modifying adjectives, i.e., predominantly, with features of, with foci of, elements of, etc.)
- Gross tumor size
- Extent of tumor spread
- Involvement of resection margins
- Number of lymph nodes involved and examined
- Record both positive and negative findings. Record positive test results first.
- Note if pathology report is a slide review or a second opinion from an outside source, i.e., AFIP, Mayo, etc.
- Record any additional comments from the pathologist, including differential diagnoses considered and any ruled out or favored
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
Primary Site
400
Laterality
410
Histologic Type ICD-O-3
522
Grade
440
Collaborative Stage variables
2800-2930
Diagnostic confirmation
490
RX Hosp--Surg Prim Site
670
RX Hosp--Scope Reg LN Sur
672
RX Hosp--Surg Oth Rg/Dis
674
RX Summ--Surg Prim Site
1290
RX Summ--Scope Reg LN Sur
1292
RX Summ--Surg Oth Reg/Dis
1294
SEER Summary Stage 2000
759
SEER Summary Stage 1977
760
Regional Nodes Positive
820
Regional Nodes Examined
830
RX Date Surgery
1200
Reason for No Surgery
1340
RX Summ--Surg/Rad Seq
1380
RX Summ--Systemic/Sur Seq
1639