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        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.
 


InstructionsPrioritize 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



    
        
        Item name
    
    
        
        Collaborative Stage variables
    
    
        
        Date of Diagnosis
    
    
        
        Diagnostic Confirmation
    
    
        
        Histology (92-00) ICD-O-2
    
    
        
        Histology ICD-O-3
    
    
        
        Laterality
    
    
        
        Primary Site
    
    
        
        RX Date-Surgery
    
    
        
        RX Hosp--Surg Prim Site
    
    
        
        RX Summ--Dx/Stg Proc
    
    
        
        SEER Summary Stage 1977
    
    
        
        SEER Summary Stage 2000
    



  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
	Collaborative Stage variables
	Date of Diagnosis
	Diagnostic Confirmation
	Histology (92-00) ICD-O-2
	Histology ICD-O-3
	Laterality
	Primary Site
	RX Date-Surgery
	RX Hosp--Surg Prim Site
	RX Summ--Dx/Stg Proc
	SEER Summary Stage 1977
	SEER Summary Stage 2000

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