layout.fixed.naaccr.doc.naaccr15.textDxProcScopes.html Maven / Gradle / Ivy

Go to download

Show more of this group Show more artifacts with this name
Show all versions of layout Show documentation

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

There is a newer version: 6.2


    
        Alternate Name
        Item #
        Length
        Source of Standard
        Column #
    
    
        
        2540
        1000
        NPCR
        7565 - 8564
    


Description
Text area for manual documentation from endoscopic examinations that provide information for staging and treatment.
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 endoscopic exam(s)
        Primary site
        Histology (if given)
        Tumor location
        Tumor size
        Record site and type of endoscopic biopsy
        Record positive and negative clinical findings. Record positive results first
    

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
        
        
            
                RX Summ--Dx/Stg Proc
            
                1350
        
        
            
                Diagnostic Confirmation
            
                490
        
        
            
                Primary Site
            
                400
        
        
            
                Laterality
            
                410
        
        
            
                Histology (92-00) ICD-O-2
            
                420
        
        
            
                Histologic Type ICD-O-3
            
                522
        
        
            
                Collaborative Stage variables
            
                2800-2930
        
        
            
                SEER Summary Stage 1977
            
                760
        
        
            
                SEER Summary Stage 2000
            
                759
        
        
            
                RX Hosp--Surg Prim Site
            
                670
        
        
            
                RX Date Surgery
            
                1200

Item name	Item number
Date of Diagnosis	390
RX Summ--Dx/Stg Proc	1350
Diagnostic Confirmation	490
Primary Site	400
Laterality	410
Histology (92-00) ICD-O-2	420
Histologic Type ICD-O-3	522
Collaborative Stage variables	2800-2930
SEER Summary Stage 1977	760
SEER Summary Stage 2000	759
RX Hosp--Surg Prim Site	670
RX Date Surgery	1200