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

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EXAMPLE F4 GASTROINTESTINAL DIAGNOSTIC REPORT Hosp. No. 000022 Name George E. McJoin Service ENT Age 74 Race White Sex Male Date 3/4/91 Medication None CLINICAL: X-RAY: Elderly male with epigastric distress, wt. loss 50 lb. Filling defect fundus - stomach ESOPHAGOGASTROSCOPY REPORT: Esophagoscope was passed with ease to the GE junction. At that point the lumen narrowed and prevented entrance of the scope into the stomach. The mucosa in the distal esophagus is erythematous, and white patches measuring 2-3 mm were noted. BIOPSY: Two mucosal biopsies taken IMPRESSION: Obstruction of distal esophagus. Etiology undetermined. Prob. carcinoma of fundus of stomach. R/O benign tumor. RECOMMENDATION: Louis Stewells, MD 137
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SEER Program Self InstructionalManu
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TABLE OF CONTENTS BOOK 5: ABSTRACTI
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SECTION A OBJECTIVES AND CONTENT OF
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SECTION B THE COMPOSITION AND ORGAN
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Physical Examination General (gener
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FORMS USED TO RECORD INFORMATION IN
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SECTION C ABSTRACTING A MEDICAL REC
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WHEN TO ABSTRACT CASES While it may
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Local Registry Number A patient's r
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Marital Status Select appropriate a
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Abstracting Diagnostic Procedures S
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SECTION D DIAGNOSTIC PROCEDURES: GE
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SECTION E CLINICAL EXAMINATIONS: PH
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EXAMPLE E1 Name: Sarah O. Luckless
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EXAMPLE E2 Name: Hector Breathless
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BODY SECTION RADIOGRAPHY. Body sect
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E. Lower GI Series or Barium Enema:
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Example E3 can be abstracted as fol
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Example E6 might be abstracted as f
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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
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 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 180 and 181: Example F15: 3/11/91. Expl. Lap.: L
Page 182 and 183: PRACTICAL EXERCISE The following pa
Page 188 and 189: These operative reports can be abst
Page 190 and 191: 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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