layout.fixed.naaccr.doc.naaccr16.textDxProcPe.html Maven / Gradle / Ivy
Alternate Name
Item #
Length
Source of Standard
Implemented Year
Implemented Version
Retired Year
Retired Version
Column #
2520
1000
NPCR
5565 - 6564
Description
Text area for manual documentation from the history and physical examination about the history of the current tumor and the clinical description of the tumor.
Rationale
Text documentation is an essential component of a complete electronic report 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 reporter independently from the code(s). If 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 software that allows unlimited text, NAACCR recommends that the software indicate to the reporter the portion of the text that will be transmitted to the central registry.
Suggestions for text:
- Date of physical exam
- Age, sex, race/ethnicity
- History that relates to cancer diagnosis
- Primary site
- Histology (if diagnosis prior to this admission)
- Tumor location
- Tumor size
- Palpable lymph nodes
- Record positive and negative clinical findings. Record positive results first
- Impression (when stated and pertains to cancer diagnosis)
- Treatment plan
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