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

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Biographical Information Sex Record male, female, or unknown. In very rare instances, the sex cannot be determined or there will be a sex change. This information should be recorded. Age at Diagnosis Birthdate This refers to years of age at time of initial diagnosis for the reported cancer. Record age at last birthday; do not round to the next birthday. Record month, day, and year of patient's birth. If any of this information is unknown, record as Unk--for instance, June, Unk, 1925. Place of Birth Record town and state for patients born in the U.S. For foreign born, record country. Some registries and registry systems have developed a code to record city, state, and country. If your registry employs such a code system, record the code as determined from your geographic location code. The SEER Program has developed a system called Geocoding which now appears in both the Data Acquisition Manual of the American College of Surgeons and the SEER Program Code Manual. Race Group There may be some problems in classifying individuals of mixed heritage--for instance, a person with a Japanese mother and a black father. Record all the details. Abbreviations on medical records can be misleading. Black is often specified as "B, .... C," or "NW"--black, colored, or non-white. However, "C" may also be used to specify Caucasian or Chinese; and Japanese patients may also be classified as "NW." Hence, when abstracting hospital records which utilize abbreviations, be sure you know exactly what the abbreviations mean. It will be of use to note a general rule in trying to distinguish between Chinese and Japanese names: usually, Chinese names have only one syllable and Japanese names have two or more syllables. Latin American and Puerto Riean are designations for ethnic groups, not races. In some sections of the country ethnic groups may be of particular interest to your registry, and you may wish to identify them--for example, Spanish surname or origin, such as Mexican, Puerto Rican, or Cuban. 19
Marital Status Select appropriate alternative: single, married, divorced, separated, widowed. Do not assume that a person specified as Miss should be classified as single. Often women who have been separated or divorced use their maiden names. A patient whose only marriage has been annulled should be classified as single. Patients having "common law" marriages should be classified as married. There may be some instances in which this information is unknown, particularly with the more frequent use of "Ms." Occupational History Record the patient's usual or major occupation and the industry in which the patient is currently or was previously employed. Also, note a secondary occupation if one is listed in the medical record. This is particularly important for determining possible carcinogenic exposure, for example, people working with asbestos or in the manufacture of polyvinyl chloride. Social History Record information on use of or contact with carcinogenic agents, such as history of smoking, drug habits, drinking, and use of birth control pills, or any other information which your Committee on Cancer requests. Medical History A. Previous Diagnosis of This Neoplasm If the reported neoplasm was first diagnosed (whether clinically or histologically) in a physician's office or at another institution, record the name of the referring physician, the name of the hospital where the diagnosis was made, the date of diagnosis, and the diagnosis (site and type). B Previous Treatment for This Neoplasm Indicate whether or not treatment was given for this neoplasm before entry to your institution. Record the date and describe briefly the nature of the treatment. This information may be contained in the referral letter or in the history section of the medical record. Copies of the diagnostic and treatment reports from the other institutions will frequently be appended to your hospital record. When information concerning previous treatment is missing from the medical record, the registry or registry system should make every effort to contact institutions or physicians who have examined or treated the patient to obtain such information. 20
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: Local Registry Number A patient's r
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 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
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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
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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_
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The manner in which the findings in
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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
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EXAMPLE F12 BRONCHOSCOPY REPORT Hos
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PRACTICAL EXERCISE ANSWERS These en
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Example F10: 5/5/91. Bronchoscopy:
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In all of the "oscopies" described
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EXAMPLE F13 OPERATIVE REPORT Name:
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This operative report may be abstra
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OPERATIVE PROCEDURES Exploratory_Su
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EXAMPLE F14 OPERATIVE REPORT Servic
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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
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Page 186 and 187:
Page 188 and 189:
These operative reports can be abst
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EXAMPLE F18A OPERATIVE REPORT Name
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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
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A. The BiopsyReport The termbiopsy(
Page 202 and 203:
EXAMPLE G1 DEPARTMENT OF PATHOLOGY
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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:
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Page 218 and 219:
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
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
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
Page 260 and 261:
COMMON ABBREVIATIONS Abbreviation T
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HEENT Head, _ eara, ame & throat LE
Page 264 and 265:
SARC Sarcoma UMB Navel (umbilicus)
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COMMON ABBREVIATIONS Definition Ind
Page 268 and 269:
Impression IMP Lumbar spine L-SPINE
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Staphylococcus STAPH Within normal
Page 272 and 273:
COMMON SYMBOLS Symbol Index Symbol
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ACRONYMS FOR ORGANIZATIONS CONCERNE
Page 276 and 277:
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
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
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