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

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EXAMPLE F5 SIGMOIDOSCOPY REPORT Rec. No. 000023 Name Lil M_S,_y Age 70 Sex Female Race White Date 2/12/91 Chief Complaint Recent change in bowel habits - alternating_constipation and diarrhea Referred by Uriah Hurtt. MD Previous Sigmoidoscopy: Date None Findings Previous Rectal Surgery: None HISTORY: 1. Blood per rectum None noted 7. Protrusion NQnf 2. Abdominal colic N_?nf 8. Change in bowel habits Alternating 3. Appetite Recfnt loss 9. Draining fistula 4. Abscess 10. Rectal pain 5. Itching 11. Fever 6. Weight Loss 5 lb, 12. Constipation See 8 above 13. Diarrhea: X Duration Constant Periodic X No. of Stools Blood None noted Mucus Cramps 14. Laboratory: Frei Serology Ova & Parasites SIGMOIDOSCOPY: Distance Scoped: 2.5 fm Interference: O Mucosa: Normal X Red Edematous Friable Ulcerated Vascular Pattern Mucus Pus Blood Granular Glistening DESCRIPTION OF OTHER PATHOLOGY AND REMARKS: Rectal - Large, firm, fungating mass on ant, (L) and post. wall of rectum Anoscopy - Same. No ulcerations. Bx's taken. Sigmoidoscopy - Fungating, lobulated mass from anal verge to 10 cm on ant, (L) and post. rectal wall. No other lesions seen. Examined by:. Will_ Prospect. MD 141
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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
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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 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
Page 192 and 193: EXAMPLE F18B OPERATIVE REPORT Name
Page 194 and 195: 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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