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

More documents

Recommendations

Info

Pathologist's Reports Exfoliative Cytologic Examinations Tissue Examinations Gross (description based on visual examination) Microscopic (description based on histologic examination) Pathologic Diagnosis (determining the disease) Final Diagnosis (made after all routine and special studies have been completed) Treatment (therapy) Reports Medication record (drugs or other medications) Surgery (report of surgery, operative report) Radiation therapy Chemotherapy Immunotherapy Physical therapy Progress Notes Doctor's Orders and Notes Nurses' Notes Discharge (Narrative) Summary Follow-up Reports Progress notes added after the patient has been discharged from the hospital: (1) Based on patient's return visits to outpatient departments (2) Based on replies to correspondence with the patient's physician, other cancer registrars, other medical facilities, with the patient or with the patient's family Autopsy Report (gross and microscopic) All of the major organs and systems are examined unless the autopsy is restricted to certain organs. Any pertinent findings should be recorded on the cancer registry abstract. The information can be of particular value in indicating the primary site of the tumor, which may have been incorrectly diagnosed or unknown prior to autopsy. Death certificate (when the patient dies in the hospital or when the death certificate is obtained through follow-up activities) 9
FORMS USED TO RECORD INFORMATION IN A MEDICAL RECORD Following is a list of most forms, records, notes, and summary sheets which may be found in your hospital's medical record. Their names are self explanatory. In this book, forms are bordered for easy identification. Some contain little or no information of interest to a cancer registrar. "Starred" (*) items are most likely to contain relevant information for filling out a cancer registry abstract. * Admission Sheet Intake-Output Chart (measured liquids) Anesthesia Record * Laboratory Reports * Autopsy (Necropsy; Post Mortem) Report * Medical Record Data Sheet (Face or Cover Sheet) * Chemotherapy Report * Medication Record * Consultation Report (Request for opinions or aid from other * Nuclear Medicine Report (Diagnostic Imaging/Scans) physicians or departments) Nuclear Medicine Report (Radio-Isotope Exposure * Cytology (Cytopathology) Report Record) * Death Certificate Nurses' Notes * Diagnostic Radiology (X-ray) Report * Operation (surgery) Report * Discharge (Narrative) Summary * Outpatient Clinic Record * Doctor's Order Sheets * Pathology (Histology) Report * Doctor's Progress Notes Physical Therapy Report Electrocardiogram (EKG) Report * Protocol Study Report * Electroencephalogram (EEG) Report * Radiation Therapy Summary Emergency (Accident) Room Report Recovery (Post-Anesthesia) Room Report * Endoscopy Report * Referral Letters (From local medical doctors or other institutions) Graphic Reports (Temperature, Pulse, Respiration, Blood Pressure) Request to Blood Bank Report * Hematology Report Serology Report * History and Physical Examination * Tumor Board Summary * Immunotherapy Report Informed Consent to Treatment I0
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 13: Physical Examination General (gener
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
Page 62: Example E6 might be abstracted as f
Page 66:
Example E7 can be abstracted as fol
Page 70:
EXAMPLE E9 Name: Hardy Smooker Hosp
Page 74:
Examples E8-E10 can be abstracted a
Page 78:
EXAMPLE Ell Name: Emma Bronchilli H
Page 81 and 82:
DIAGNOSTIC NUCLEAR MEDICINE EXAMINA
Page 84:
EXAMPLE El2 THE DIVISION OF NUCLEAR
Page 88:
EXAMPLE E14 Record No.: 000014 Name
Page 92:
MAGNETIC RESONANCE IMAGING: Magneti
Page 96:
EXAMPLEE16 MRI CONSULTATIONREPORT N
Page 100 and 101:
HEMATOLOGIC EXAMINATION A hematolog
Page 102 and 103:
Granulocytes or granular leukocytes
Page 104 and 105:
Certain types of disease associated
Page 106 and 107:
EXAMPLE E17 HEMATOLOGY LABORATORY N
Page 108 and 109:
EXAMPLEE18 HEMATOLOGY LABORATORY Na
Page 110 and 111:
EXAMPLE E19 HEMATOLOGY LABORATORY R
Page 112 and 113:
PRACTICAL EXERCISE ANSWERS Example
Page 114 and 115:
Bone Marrow Studies. Examination of
Page 116 and 117:
EXAMPLE E20 Name: Bo Comeaway Hospi
Page 118 and 119:
Example E20 can be abstracted as fo
Page 120 and 121:
Blood Serum Studies Automation and
Page 122 and 123:
Other Laboratory Studies Marrow Aci
Page 124 and 125:
Totalprotein. This test measures th
Page 126 and 127:
SECTION F MANIPULATIVE AND OPERATIV
Page 128 and 129:
SECTION F MANIPULATIVE AND OPERATIV
Page 130 and 131:
EXAMPLE FI Rec. No. 000019 Name Iv_
Page 132 and 133:
The manner in which the findings in
Page 134 and 135:
EXAMPLE F2 LARYNGOSCOPY REPORT Hosp
Page 136 and 137:
The illustrated report can be abstr
Page 138 and 139:
I EXAMPLE F3 REPORT OF CYSTOSCOPY N
Page 140 and 141:
Example F3 is abstracted as follows
Page 142 and 143:
EXAMPLE F4 GASTROINTESTINAL DIAGNOS
Page 144 and 145:
The information described in Exampl
Page 146 and 147:
EXAMPLE F5 SIGMOIDOSCOPY REPORT Rec
Page 148 and 149:
EXAMPLE F6 PROCTOSCOPY REPORT Rec.
Page 150 and 151:
EXAMPLE F7 GASTROSCOPIC REPORT Hosp
Page 152 and 153:
EXAMPLE F8 GASTROSCOPIC REPORT Hosp
Page 154 and 155:
EXAMPLE F9 BRONCHOSCOPY REPORT Hosp
Page 156 and 157:
EXAMPLE FIO BRONCHOSCOPY REPORT Hos
Page 158 and 159:
EXAMPLE Fll BRONCHOSCOPY REPORT Hos
Page 160 and 161:
EXAMPLE F12 BRONCHOSCOPY REPORT Hos
Page 162 and 163:
PRACTICAL EXERCISE ANSWERS These en
Page 164 and 165:
Example F10: 5/5/91. Bronchoscopy:
Page 166 and 167:
In all of the "oscopies" described
Page 168 and 169:
EXAMPLE F13 OPERATIVE REPORT Name:
Page 170 and 171:
This operative report may be abstra
Page 172 and 173:
OPERATIVE PROCEDURES Exploratory_Su
Page 174 and 175:
EXAMPLE F14 OPERATIVE REPORT Servic
Page 176 and 177:
The operative record used as an ill
Page 178 and 179:
Page 180 and 181:
Example F15: 3/11/91. Expl. Lap.: L
Page 182 and 183:
PRACTICAL EXERCISE The following pa
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
These operative reports can be abst
Page 190 and 191:
EXAMPLE F18A OPERATIVE REPORT Name
Page 192 and 193:
EXAMPLE F18B OPERATIVE REPORT Name
Page 194 and 195:
Example F18 can be abstracted as fo
Page 196 and 197:
SECTION G PATHOLOGICAL EXAMINATIONS
Page 198 and 199:
SECTION G PATHOLOGICAL EXAMINATIONS
Page 200 and 201:
A. The BiopsyReport The termbiopsy(
Page 202 and 203:
EXAMPLE G1 DEPARTMENT OF PATHOLOGY
Page 204 and 205:
Example G1 can be abstracted as fol
Page 206 and 207:
Abstracting the Pathology Report Le
Page 208 and 209:
EXAMPLE G2 PATHOLOGY REPORT Path. N
Page 210 and 211:
EXAMPLE G3 PATHOLOGICAL SPECIMEN RE
Page 212 and 213:
Page 214 and 215:
EXAMPLE (34 (continued) DIAGNOSIS:
Page 216 and 217:
Page 218 and 219:
The information which should be abs
Page 220 and 221:
PRACTICAL EXERCISE In the following
Page 222 and 223:
EXAMPLE G6 PATHOLOGY REPORT Name Be
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
PRACTICAL EXERCISE ANSWERS Example
Page 232 and 233:
EXAMPLE G10 AUTOPSY REPORT IDENTIFI
Page 234 and 235:
EXAMPLE G10 (continued) CLINICOPATH
Page 236 and 237:
Example G10 can be abstracted as fo
Page 238 and 239:
EXAMPLE Gll DEPARTMENT OF PATHOLOGY
Page 240 and 241:
EXAMPLE G11 (Continued) DEPARTMENT
Page 242 and 243:
EXAMPLE Gll (Continued) DEPARTMENT
Page 244 and 245:
Example G11 can be abstracted as fo
Page 246 and 247:
CYTOLOGIC EXAMINATION The study of
Page 248 and 249:
A cytology report recorded as suspi
Page 250 and 251:
PRACTICAL EXERCISE Summarize the fi
Page 252 and 253:
EXAMPLE G13 i ! PATIENT NO. DATE 10
Page 254 and 255:
EXAMPLE G14 Patient No. 000050 DATE
Page 256 and 257:
EXAMPLE GI_ CLINICAL RECORD - TISSU
Page 258 and 259:
Examples G12-15 may be abstracted a
Page 260 and 261:
COMMON ABBREVIATIONS Abbreviation T
Page 262 and 263:
HEENT Head, _ eara, ame & throat LE
Page 264 and 265:
SARC Sarcoma UMB Navel (umbilicus)
Page 266 and 267:
COMMON ABBREVIATIONS Definition Ind
Page 268 and 269:
Impression IMP Lumbar spine L-SPINE
Page 270 and 271:
Staphylococcus STAPH Within normal
Page 272 and 273:
COMMON SYMBOLS Symbol Index Symbol
Page 274 and 275:
ACRONYMS FOR ORGANIZATIONS CONCERNE
Page 276 and 277:
WORLDWIDE ORGANIZATIONS IACR Intern
Page 278 and 279:
ACRONYMS FOR STUDY GROUPS The follo
Page 280 and 281:
SELECTED BIBLIOGRAPHY Cancer Regist
Page 282 and 283:
INDEX Abstract, 3, 9, 11, 15-17, 21
Page 284 and 285:
Cerebral angiogram, 40 Chemistry (S
Page 286 and 287:
Endoscopic examination (Cont'd) Exa
Page 288 and 289:
Laryngogram, 65, 69 Example E9, 65,
Page 290 and 291:
Papanicolaou classification, 243 Pa
Page 292 and 293:
Special examinations, 8 SPECT, 71 S
Page 294 and 295:
Index of Examples E_mmple E1 29, 31
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?