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

More documents

Recommendations

Info

EXAMPLE Fll BRONCHOSCOPY REPORT Hospital No. 000029 Name Minnie Mumm Service ENT Sex Female Age 48 Race White Date of Operation 6/10/91 Clinical Diagnosis Carcinoma of the esophagus Procedure Esophagoscopy Anesthetic Larynx: Normal Pharynx: Normal Trachea: Right Bronchus: Not visualized Left Bronchus: Not visualized Esophagus: Carcinoma of the esophagus at 18 cm. Biopsy taken. Diagnosis: Carcinoma of the esophagus Remarks: Endoscopist A. H. Access, MD Assistant Rich Shaw, MD 153
154
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 and 14:
Physical Examination General (gener
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
Page 54:
Page 58:
Page 62:
Example E6 might be abstracted as f
Page 66:
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 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
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:
EXAMPLE G4 DEPARTMENT OF PATHOLOGY
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 ...

Create successful ePaper yourself

Delete template?

Save as template?