layout.fixed.naaccr.doc.naaccr12.textDxProcPe.html Maven / Gradle / Ivy

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Framework that allows defining file formats (layouts) and use them to read and write data files.

There is a newer version: 6.1


    
        Alternate Name
        Item#
        Length
        Source of Standard
        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 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 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 1st Contact
        580
    
    
        
        Date of Diagnosis
        390
    
    
        
        Age at Diagnosis
        230
    
    
        
        Race 1 - 5
        160-164
    
    
        
        Spanish Hispanic Origin
        190
    
    
        
        Sex
        220
    
    
        
        Primary Site
        400
    
    
        
        Laterality
        410
    
    
        
        Histologic Type ICD-O-3
        522
    
    
        
        Sequence Number--Hospital
        560
    
    
        
        Collaborative Stage variables
        2800-2930
    
    
        
        SEER Summary Stage 1977
        760
    
    
        
        SEER Summary Stage 2000
        759

	Item name	Item number
	Date of 1st Contact	580
	Date of Diagnosis	390
	Age at Diagnosis	230
	Race 1 - 5	160-164
	Spanish Hispanic Origin	190
	Sex	220
	Primary Site	400
	Laterality	410
	Histologic Type ICD-O-3	522
	Sequence Number--Hospital	560
	Collaborative Stage variables	2800-2930
	SEER Summary Stage 1977	760
	SEER Summary Stage 2000	759