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

HOW TO ABSTRACT CANCER REGISTRY INFORMATION
Certain information is basic to any abstract, such as the medical record number, diagnosis, date of
diagnosis, age, sex, race, treatment, date of last follow-up, and status of the patient at last follow-up. For a
detailed list of information requirements for a cancer registry see the Data Acquisition Manual of the
Commission on Cancer, American College of Surgeons. Other information is optional depending upon the
scope of your registry. The detailed description that follows is designed to fit the needs of all users--hospitals,
clinics, and central registry systems.
Patient Identification
Name
Use full name of patient whenever possible. If middle and maiden names are given, record both. Very
often the middle (or maiden) name will be given only as an initial and should be so recorded. However,
every effort should be made to avoid the use of initials for first names.
For married women, the first name of the husband should not be used; record the name of married
female patients, for example, as Jones, Paula Ann, not Jones, Mrs. John T. The husband's name will
be recorded under the heading "Spouse."
In recording the name of Catholic clergy, it is preferable to use family names, if known. Use the title
(Sister, Brother, Father, Mother) as a family name only until the true family name is known. A cross
reference will probably be necessary to facilitate this matching of names and avoid duplication.
For male patients who are Sr., Jr., III, etc., so indicate following the last name. Also, if it is known that
the patient has a graduate professional degree (M.D., D.D.S., D.D.), indicate--for example, Smith, III,
M.D., Robert Quintin.
Hospital Medical Record Number
Record the number assigned to the patient by the hospital admitting office. If the hospital has a unit
numbering system, all patient records will carry this identifying number. If the hospital has a serial
numbering system, a new number is assigned on each admission to the hospital. In this case each
registry must work out a system which will best serve as a cross reference to the hospital medical record,
for example, an alphabetic card index file. This file can then be checked against the medical record
department's alphabetic file to determine the patient's latest admission. You may decide to retain as
your registry number, the number assigned the patient by the hospital at the time the neoplasm was first
diagnosed. If the hospital has a serial unit system, each admission is given a unique number, such as an
accounting number, but the patient's record is filed under a unit number in medical records.
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