Slide 1 Requirements for Abstracted Text Principles of Abstracting Lesson 3: Purpose of Text
Slide 2 Available Text Fields Place of Diagnosis Immunotherapy Chemotherapy Hormone Therapy Other Therapy Radiation Radiation, Other Surgery Laboratory Tests Physical Examination Operative Pathology Scopes X-Rays and Scans Histology Primary Site Remarks Stage There are many different text fields in which information can be entered. But, what kind of information belongs in each of these fields? The text fields are provided as a guide as to the type of information that is needed to help describe this patient s cancer story. The following slides will help identify the type of information needed to effectively justify the coded data items.
Slide 3 Required Reading The text fields are described in Chapter X: Data Dictionary in the NAACCR Standards for Cancer Registries, Volume II, Data Standards and Data Dictionary. As each type of text field is discussed, also read the corresponding pages in the Data Standards and Data Dictionary. The reading assignment will be listed in a blue box on the appropriate slides. For each reading assignment, pay particular attention to the following sections: rationale, instructions, suggestions for text, and data items verified. Reading Assignment: Data Item Name Page Number Slide 4 Key Information For each type of report, a green circle, like the one on the right, will list key information the cancer registrar should look for and pay particular attention to when reviewing the medical record. The findings from these key areas should be included in the abstracted text. Location of tumor Tumor size Extension to adjacent tissues Evaluation of lymph nodes and distant mets Positive and negative findings
Slide 5 DATES! First of all, dates are very important. Always include the dates of when procedures were done and when treatment started and ended. This helps justify the date of diagnosis as well as all other date fields.
Slide 6 Text Place of Diagnosis Where the patient was diagnosed Another facility Physician s office Another state Reading Assignment: Place of Diagnosis Page 418-419 Record where the patient was diagnosed. The patient may have been diagnosed at another hospital, in a physician s office, or maybe even in another state. This data item helps validate the class of case and provides an insight as to the source of the information that you are providing. For example, if the patient was diagnosed in another state and is admitted to your facility for treatment, then more than likely the information pertaining to the biopsy was obtained from dictated reports in the medical record and not from the actual diagnostic reports.
Slide 7 Text Treatment (all) Date of procedures and/or treatment Type of procedures and/or treatment Facility that delivered the treatment Pre-operative treatment Record all treatment information known even if not delivered at your facility Reading Assignment: Rx Text -- BRM through Rx Text -- Surgery Pages 373-382 For all types of treatment modalities, include start and end dates and justify all surgical procedures as well as any diagnostic, staging and palliative procedures (biopsies, by-pass surgery, etc.). Be sure there is documentation in the text to justify all of the treatment codes. The facility where the treatment was given should be included in the text, especially if it was not given at the reporting facility. If treatment was delivered preoperatively, indicate that as well. Pre-operative treatment affects how other fields are coded such as tumor size. Also, all treatment given as the planned first course of therapy should be recorded, including treatment given at another facility or in the physician s office.
Slide 8 Text Treatment (all) Surgery All surgical procedures Diagnostic, staging, and palliative procedures Radiation (Regional and Boost) Beam RT RT other than beam Seeds for prostate I-131 for thyroid Area (target) treated Amount of cgy s and modality Systemic Therapy Agents or treatment In addition to the basic text information that applies to all treatment types, the following information should also be documented for the specified treatment types. Surgery: Include documentation to justify all of the surgical procedures fields. If more than one surgical procedure was performed, the text should specify each procedure and the date performed separately. Text should also include a description of any biopsies or diagnostic procedures. Radiation Therapy: There are several fields that describe the regional and boost treatment that a patient may receive. In addition, to listing the dates and treatment volume (anatomic target), the text should also describe modality and dosage for both regional and boost treatment. Systemic Therapy: For chemotherapy, hormone therapy, and immunotherapy, record the agents and/or treatment given, including the dates and place. Always refer to SEER Rx Database to ensure that the agents being coded are considered cancer directed and that they are being coded under the appropriate data field.
Slide 9 Text Lab Tests/Scopes/Scans Date of procedure Type of procedure Results of procedure Reading Assignment: Text--Dx Proc--Lab Tests Through Text--Dx Proc--X-Ray/Scan Pages 408-417 Location of tumor Tumor size Extension to adjacent tissues Evaluation of lymph nodes and distant mets Positive and negative findings Record findings from laboratory, imaging and endoscopic reports. Record both the negative and positive results that relate to this cancer. As part of the diagnostic workup, the physician must determine the extent of the disease before making a determination on the best coarse of treatment. Different primary sites require different types of workup. So there may not always be every type of workup for every case. The checklist in the circle is something to keep in mind to look for while you are reviewing these reports. Where is the tumor located? How big is it? Are adjacent tissues involved? Is there adenopathy? What about involvement of distant sites? And if any of this workup is negative, then be sure to document that as well.
Slide 10 Text Physical Exam Age, race, sex Example: 53yo WM Dates of examinations Relevant symptoms and findings Rectal bleeding, fever and night sweats, RUQ pain Palpable breast mass, rectal mass, dark brown lesion with irregular borders The age, race, and sex of the patient should be documented in the text. This allows errors with date of birth and date of diagnosis to be checked as well as the race and sex data items. This information also helps document unusual age/site/histology combinations. For example, a 25 year old male with colon cancer is an uncommon, but possible occurrence. The text can be used to verify the age and primary site when the edit is created without having to re-pull the medical record to confirm that patient s information. Record relevant symptoms and findings. But, what is relevant? A few examples are listed below: 1) Is rectal bleeding for a patient with suspected breast cancer relevant? Perhaps. If the workup is consistent with hemorrhoids, then this information is most likely not relevant to the patient s diagnosis of breast cancer. 2) Is rectal bleeding relevant for a patient with suspected colon cancer? Most likely the bleeding is due to the cancer and should be documented in the text. 3) Is the patient s other conditions, such as COPD, relevant? It is possible for this type of information to be relevant, particularly if the patient is not be treated because of their severe COPD.
Slide 11 Text - Operative Information from the operative report Intra-operative findings Record findings from any operative procedures. In particular, include any findings from what the surgeon observes or sees during the actual operative procedure. Was there any gross or visual tumor? Was the liver palpated and what were the findings? This is particularly important for open surgical procedures such as those for ovarian cancer in which an exploration of the abdomen or body cavity may be done.
Slide 12 Text Pathology Date of procedure Type of procedure Pertinent findings Final diagnosis Reading Assignment: Text--Histology Title, p417-418 Text--Primary Site Title, p420 Location of tumor Tumor size Involvement of adjacent tissues, lymph nodes, and distant mets Surgical Margins Tumor Grade Histology Positive and negative findings Record pertinent information from the pathology, cytology, and autopsy reports. Especially the final diagnosis as written on the report and include the primary site, histology, grade, and margins. Often, the grade and surgical margins are omitted from the text documentation. Include relevant findings and the gross examination including aids in identifying the primary site and extent of disease. It is important to differentiate between the organs that were taken or sampled and those that were involved with cancer. For example, the text may read, Ovary, tubes, uterus, omentum, cul-de-sac, bladder consistent with adenocarcinoma. Were all of these organs involved? Or, were all of these organs sampled and only the uterus contained cancer?
Slide 13 Text - Remarks Justify multiple primaries Helpful comments Quality control remarks Document the unusual Justify the setting of an over-ride flag Reading Assignment: Text--Remarks Page 421 The remarks text field is an additional text field that may be used to justify or document information that may not fall under any of the other headings, such as history of other primaries, or statements of recurrence or multiple primaries. It may also be used for any comments that you feel are necessary to help explain this case, hospital-specific information that the cancer committee requires, quality control remarks or to document the unusual. This type of documentation will be discussed in more in detail later in this lesson.
Slide 14 Text Stage What information from the source document did you use to stage the cancer? Summarize findings from both clinical and pathological evaluations. Reading Assignment: Text--Staging Page 422-423 Invasiveness Involvement and extension of surrounding tissues Lymph node involvement Results of metastatic work-up This field can be used to summarize the clinical and pathological findings that were used to assign the summary stage, AJCC stage, and Collaborative Stage data items. For example, you may provide thorough findings from the scans in the x-ray/scan text field and the thorough findings from the pathology in the pathology text fields. All of that information does not need to be repeated verbatim in the stage text field. For example, a summation for a local colon cancer may be: Local, tumor involved subserosa, 3 lymph nodes negative, metastatic work-up neg. This is a summary of all of the details contained in the other text fields that the stage is indeed local. Again, the circle contains a brief checklist of criteria to keep in mind in determining whether or not you have provided enough information to justify the summary stage.
Slide 15 Text should be. Short Concise Complete It may appear as though text documentation results in volumes of information in the abstract. However, it should be emphasized that text should be short and concise, but most importantly, complete. Ways to document text efficiently and effectively will be discussed in later sections of this lesson.