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layout.fixed.naaccr.doc.naaccr14.rxTextChemo.html Maven / Gradle / Ivy
Alternate Name
Item #
Length
Source of Standard
Column #
2640
1000
NPCR
15765 - 16764
Description
Text area for manual documentation of information regarding chemotherapy treatment of the reported 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 chemotherapy began
- Where treatment was given, e.g., at this facility, at another facility
- Type of chemotherapy, e.g., name of agent(s) or protocol
- Other treatment information, e.g., treatment cycle incomplete, unknown if chemotherapy was given
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 Initial RX SEER
1260
Date 1st Crs RX CoC
1270
RX Hosp--BRM
720
RX Date Systemic
3230
RX Summ--Tranplnt/Endocr
3250
RX Summ--BRM
1410
RX Date BRM
1240
RX Summ--Systemic/Sur Seq
1639
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