The Components of an Abstract. Alfreda Woods, BS, CHES, CTR Program Manager, DCCR DelMarVa-DC Educational Conference October 12, 2018

Transcription

1 The Components of an Abstract Alfreda Woods, BS, CHES, CTR Program Manager, DCCR DelMarVa-DC Educational Conference October 12,

2 Abstracts Should Tell A Story 2

3 The Components of an Abstract Who (Patient Demographics) Name Sex *Race * Marital Status Social History Family Hx Prior cancer history 3

4 Where The Components of an Abstract Cancer location (Primary Site) Patient diagnosis Diagnosing/Treating facility 4

5 The Components of an Abstract Address at Diagnosis - NAACCR Item # 2330 Intended to store street address information for the patient s physical, residential address. If the patient has multiple tumors, address at diagnosis may be different for each tumor. Do not update this item if the patient s residential address changes. Geocoding or consolidation Refer to STORE for residency rules NAACCR Standards for Cancer Registries, Volume II: Data Standards and Data Dictionary, Chapter X: Data Dictionary 5

6 The Components of an Abstract Address at Diagnosis, cont. Spell entire address name (100 Martin Luther King Avenue) Abbreviations should be limited to those recognized by USPS standard abbreviations Additional address information such as facility, nursing home, name of apartment complex, or a PO Box used for mailing purposes, should be entered in Addr At Dx--Supplementl [2335]. The address should be fully spelled out with standardized use of abbreviations and punctuation per USPS postal addressing standards. Mixed case allowed Punctuation marks should be avoided, except when punctuation is necessary to convey the meaning NAACCR Standards for Cancer Registries, Volume II: Data Standards and Data Dictionary, Chapter X: Data Dictionary 6

7 The Components of an Abstract APT apartment N north BLDG building NE northeast FL floor NW northwest STE suite S south UNIT unit SE Southeast RM room SW southwest DEPT department E east W west NAACCR Standards for Cancer Registries, Volume II: Data Standards and Data Dictionary, Chapter X: Data Dictionary 7

8 The Components of an Abstract What Type of cancer diagnosis (SCC, Adenoca, Lymphoma, etc.) diagnosis Paired organ (Laterality) 8

9 When The Components of an Abstract Date of Diagnosis Date of 1 st Contact How Diagnostic Procedure Colonoscopy, EGD, Bronchoscopy, etc. Biopsy/Cytology Autopsy Radiologic Imaging 9

10 The Components of an Abstract Why (Determined by Research) Risk factors (social hx, age, race) Genetics Tumor markers Cancer Clusters Socio-economic factors 10

11 Appropriate Use of Text Fields 11

12 Appropriate Use of Text Fields NAACCR Text Guidelines The text field is an essential component of complete electronic report 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 Must contain a description that has been entered by the registrar independently from the codes. It is not repetition. 12

13 Required Text Fields Patient Demographics 100 characters each Text Usual Occupation Text Usual Industry Diagnosis and Staging (1000) Text DX Proc PE Text Dx Proc X-ray/Scan Text DX Proc Scopes Text DX Proc Lab Tests Text DX Proc Operative Report Text DX Proc Pathology Report Text Staging Text Remarks Tumor Information Text Place of Diagnosis (60) Text Primary Site Title (100) Text Histology Title (100) Treatment (1000) RX Text Surgery RX Text Radiation (Beam) RX Text Chemotherapy RX Text Hormone RX Text BRM RX Text Other NAACCR Standards for Cancer Registries, Version 11 Chapter VIII: Required Status Table 13

14 Appropriate Use of Text Fields NAACCR Text Guidelines Place information in chronological order Use NAACCR-approved abbreviations (Appendix G) Do not repeat information from other text fields Do not include irrelevant information Do not include information that the registry is not authorized to collect Document if information is missing from the patient record Do not perform AUTO CODING Review Data Dictionary text suggestions for each text field NAACCR Standards for Cancer Registries, Volume II: Data Standards and Data Dictionary, Chapter X: Data Dictionary 14

15 APPROPRIATE USE OF TEXT FIELDS Suggestions for text: (ex: Dx Proc (X-ray/Scan) Date(s) and type(s) of X-ray/Scan(s) Primary site Histology (if given) Tumor location Tumor size Lymph nodes Record positive and negative clinical findings. Record positive results first Distant disease or metastasis 15

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