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


    
        Alternate Name
        Item #
        Length
        Source of Standard
        Column #
    
    
        
        2550
        1000
        NPCR
        8565 - 9564
    


Description
Text area for manual documentation of information from laboratory examinations other than cytology or histopathology.
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:
    
        Type of lab test/tissue specimen(s)
        Record both positive and negative findings. Record positive test results first.
        Information can include tumor markers, serum and urine electrophoresis, special studies, etc.
        Date(s) of lab test(s)
        Tumor markers included, but are not limited to:
        
            Breast Cancer – Estrogen Receptor Assay (ERA), Progesterone Receptor Assay (PRA), Her2/neu.
             Prostate Cancer – Prostatic Specific Antigen (PSA)
             Testicular Cancer – Human Chorionic Gonadotropin (hCG), Alpha Fetoprotein (AFP), Lactate Dehydrogenase (LDH)
        
    

  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
        
        
            
                Primary Site
            
                400
        
        
            
                Grade
            
                440
        
        
            
                Diagnostic Confirmation
            
                490
        
        
            
                Collaborative Stage variables
            
                2800-2930
        
        
            
                Date of Diagnosis
            
                390
Item name	Item number
Primary Site	400
Grade	440
Diagnostic Confirmation	490
Collaborative Stage variables	2800-2930
Date of Diagnosis	390