All Downloads are FREE. Search and download functionalities are using the official Maven repository.

layout.fixed.naaccr.doc.naaccr21.textDxProcOp.html Maven / Gradle / Ivy

Item # Length Source of Standard Year Implemented Version Implemented Year Retired Version Retired Column #
2560 1000 NPCR 10935 - 11934

NAACCR XML: Tumor.textDxProcOp

Description
Text area for manual documentation of all surgical procedures that provide information for staging.
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:
  • Dates and descriptions of biopsies and all other surgical procedures from which staging information was derived
  • Number of lymph nodes removed
  • Size of tumor removed
  • Documentation of residual tumor
  • Evidence of invasion of surrounding areas
  • Reason primary site surgery could not be completed
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

RX Hosp--Dx/Stg Proc

740

RX Summ--Surg Prim Site

1290

Collaborative Stage variables

2800-2930

SEER Summary Stage 1977

760

SEER Summary Stage 2000

759

Reason for No Surgery

1340

Summary Stage 2018

764

AJCC TNM Data Items

1001-1036

EOD Data Items

772-776

Site-specific SSDI Data Items

3801-3937





© 2015 - 2025 Weber Informatics LLC | Privacy Policy