Self Instructional Manual for Cancer Registrars - SEER - National ...

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SECTION B THE COMPOSITION AND ORGANIZATION OF A MEDICAL RECORD A medical record may be quite simple, containing only a few pages; or it may be extremely complex containing a variety of reports, many of which will be handwritten. It is imperative that you master medical terminology to the best of your ability not only because of the unfamiliar terms you will encounter, but because of the difficulty in deciphering physicians' handwriting. If you know your root words and how to use your medical dictionary, you can generally decipher most medical terms. You may also refer to other portions of the medical record for clues as to what the incomprehensible term might be. Request assistance from your medical consultant if necessary. In any case, familiarize yourself with the diagnostic procedures used in your hospital so that you are aware when information is missing or when a record is incomplete. Medical records have certain characteristics in common. It is these fundamental characteristics which you will study in this block of instruction. COMPOSITION OF A MEDICAL RECORD The following is a list of specific types of information contained in most medical records. The information will not necessarily appear in this order. Patient Referral Identification Information Biographical Information Medical History Chief Complaint (CC) (date of onset and description of symptoms) Review of Systems (R.O.S.) Personal Medical History (to include medically-related social history, for example, drinking, drug habits, smoking and exposure to other carcinogens) Family Medical History (especially history of cancer in the family) 7
Physical Examination General (general patient description by MD) Head Eyes Ears Nose and Sinuses Mouth Throat Neck Thorax Lymph Nodes Cardiovascular System Lungs Breasts Abdomen Genitourinary System Rectum Bones, Joints, and Muscles Nervous and Mental State (neurologic condition) Extremities Provisional Diagnosis (admitting diagnosis, first impression) Special Examinations Radiologic Examinations (diagnostic x-rays) EKG (electrocardiogram) Diagnostic Imaging Nuclear Examinations (scans) Laboratory Reports: Urinalysis, hematologic analysis* (blood chemistries), other chemistries, serology, and cultures Consultation Reports Endoscopic Examinations Exploratory Surgery *Simultaneous Multiple Analysis may be used--This is an automatic analyzer that measures different chemistries. For example, SMA-6 may measure sodium, potassium, chloride, carbon dioxide, BUN, glucose, and creatinine. SMA-12 may measure calcium, alkaline phosphatase, SGOT, bilirubin, phosphate, LDH, uric acid, creatinine, BUN, total protein, albumin, glucose, and cholesterol. 8
Page 2 and 3: SEER Program Self InstructionalManu
Page 4 and 5: TABLE OF CONTENTS BOOK 5: ABSTRACTI
Page 6: SECTION A OBJECTIVES AND CONTENT OF
Page 10: SECTION B THE COMPOSITION AND ORGAN
Page 15 and 16: FORMS USED TO RECORD INFORMATION IN
Page 18: SECTION C ABSTRACTING A MEDICAL REC
Page 21 and 22: WHEN TO ABSTRACT CASES While it may
Page 23 and 24: Local Registry Number A patient's r
Page 25 and 26: Marital Status Select appropriate a
Page 27 and 28: Abstracting Diagnostic Procedures S
Page 30 and 31: SECTION D DIAGNOSTIC PROCEDURES: GE
Page 32: SECTION E CLINICAL EXAMINATIONS: PH
Page 36: EXAMPLE E1 Name: Sarah O. Luckless
Page 40: EXAMPLE E2 Name: Hector Breathless
Page 44 and 45: BODY SECTION RADIOGRAPHY. Body sect
Page 46: E. Lower GI Series or Barium Enema:
Page 50: Example E3 can be abstracted as fol
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Example E6 might be abstracted as f
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Example E7 can be abstracted as fol
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EXAMPLE E9 Name: Hardy Smooker Hosp
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Examples E8-E10 can be abstracted a
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EXAMPLE Ell Name: Emma Bronchilli H
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DIAGNOSTIC NUCLEAR MEDICINE EXAMINA
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EXAMPLE El2 THE DIVISION OF NUCLEAR
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EXAMPLE E14 Record No.: 000014 Name
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MAGNETIC RESONANCE IMAGING: Magneti
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EXAMPLEE16 MRI CONSULTATIONREPORT N
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HEMATOLOGIC EXAMINATION A hematolog
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Granulocytes or granular leukocytes
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Certain types of disease associated
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EXAMPLE E17 HEMATOLOGY LABORATORY N
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EXAMPLEE18 HEMATOLOGY LABORATORY Na
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EXAMPLE E19 HEMATOLOGY LABORATORY R
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PRACTICAL EXERCISE ANSWERS Example
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Bone Marrow Studies. Examination of
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EXAMPLE E20 Name: Bo Comeaway Hospi
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Example E20 can be abstracted as fo
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Blood Serum Studies Automation and
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Other Laboratory Studies Marrow Aci
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Totalprotein. This test measures th
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SECTION F MANIPULATIVE AND OPERATIV
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SECTION F MANIPULATIVE AND OPERATIV
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EXAMPLE FI Rec. No. 000019 Name Iv_
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The manner in which the findings in
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EXAMPLE F2 LARYNGOSCOPY REPORT Hosp
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The illustrated report can be abstr
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I EXAMPLE F3 REPORT OF CYSTOSCOPY N
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Example F3 is abstracted as follows
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EXAMPLE F4 GASTROINTESTINAL DIAGNOS
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The information described in Exampl
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EXAMPLE F5 SIGMOIDOSCOPY REPORT Rec
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EXAMPLE F6 PROCTOSCOPY REPORT Rec.
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EXAMPLE F7 GASTROSCOPIC REPORT Hosp
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EXAMPLE F8 GASTROSCOPIC REPORT Hosp
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EXAMPLE F9 BRONCHOSCOPY REPORT Hosp
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EXAMPLE FIO BRONCHOSCOPY REPORT Hos
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EXAMPLE Fll BRONCHOSCOPY REPORT Hos
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EXAMPLE F12 BRONCHOSCOPY REPORT Hos
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PRACTICAL EXERCISE ANSWERS These en
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Example F10: 5/5/91. Bronchoscopy:
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In all of the "oscopies" described
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EXAMPLE F13 OPERATIVE REPORT Name:
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This operative report may be abstra
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OPERATIVE PROCEDURES Exploratory_Su
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EXAMPLE F14 OPERATIVE REPORT Servic
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The operative record used as an ill
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Example F15: 3/11/91. Expl. Lap.: L
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PRACTICAL EXERCISE The following pa
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These operative reports can be abst
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EXAMPLE F18A OPERATIVE REPORT Name
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EXAMPLE F18B OPERATIVE REPORT Name
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Example F18 can be abstracted as fo
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SECTION G PATHOLOGICAL EXAMINATIONS
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SECTION G PATHOLOGICAL EXAMINATIONS
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A. The BiopsyReport The termbiopsy(
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EXAMPLE G1 DEPARTMENT OF PATHOLOGY
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Example G1 can be abstracted as fol
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Abstracting the Pathology Report Le
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EXAMPLE G2 PATHOLOGY REPORT Path. N
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EXAMPLE G3 PATHOLOGICAL SPECIMEN RE
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EXAMPLE (34 (continued) DIAGNOSIS:
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The information which should be abs
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PRACTICAL EXERCISE In the following
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EXAMPLE G6 PATHOLOGY REPORT Name Be
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PRACTICAL EXERCISE ANSWERS Example
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EXAMPLE G10 AUTOPSY REPORT IDENTIFI
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EXAMPLE G10 (continued) CLINICOPATH
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Example G10 can be abstracted as fo
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EXAMPLE Gll DEPARTMENT OF PATHOLOGY
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EXAMPLE G11 (Continued) DEPARTMENT
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EXAMPLE Gll (Continued) DEPARTMENT
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Example G11 can be abstracted as fo
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CYTOLOGIC EXAMINATION The study of
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A cytology report recorded as suspi
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PRACTICAL EXERCISE Summarize the fi
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EXAMPLE G13 i ! PATIENT NO. DATE 10
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EXAMPLE G14 Patient No. 000050 DATE
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EXAMPLE GI_ CLINICAL RECORD - TISSU
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Examples G12-15 may be abstracted a
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COMMON ABBREVIATIONS Abbreviation T
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HEENT Head, _ eara, ame & throat LE
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SARC Sarcoma UMB Navel (umbilicus)
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COMMON ABBREVIATIONS Definition Ind
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Impression IMP Lumbar spine L-SPINE
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Staphylococcus STAPH Within normal
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COMMON SYMBOLS Symbol Index Symbol
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ACRONYMS FOR ORGANIZATIONS CONCERNE
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WORLDWIDE ORGANIZATIONS IACR Intern
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ACRONYMS FOR STUDY GROUPS The follo
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SELECTED BIBLIOGRAPHY Cancer Regist
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INDEX Abstract, 3, 9, 11, 15-17, 21
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Cerebral angiogram, 40 Chemistry (S
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Endoscopic examination (Cont'd) Exa
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Laryngogram, 65, 69 Example E9, 65,
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Papanicolaou classification, 243 Pa
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Special examinations, 8 SPECT, 71 S
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Index of Examples E_mmple E1 29, 31
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