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

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COMMON ABBREVIATIONS Abbreviation Term(.0 Abbreviation Index A Allergy A Annum APP Appendix A Anode APPROX Appt_mately A Anterior ARC Aids related oomplet A Aortic ARD(S) Acute rca_toly disease (syndrome) A Artery ART Artety(ial) A Axial AS Aortic t_aeais AB Abort (miscarry) AS Art_ AB About ASCVD Afletimcletx]_ cardiovascular disease AB Antibody ASHD Aflesimdesmic heart disease AB Asthmatic bronchitis ASP Aspiration ABD, ABDOM Abdomen ASR _ secretion rate ABN Abnormal ASS Anterior superior spine (of ilium) ABP Arterial blood pressure A STEN Am'tic getmm ABST Abstract ATP Adenotine triphosphate AC Adrenal corte_t ATR Achilles tendon reflect AC Air contrast ATR Atrophy AC Anterior chamber AU Angstrom unit ACH Adrenal cortical hormone AU Aurum (gold, chemical symbol for) ACID PHOS Acid phosphatase AUT Autopsy ACID P'I'ASE Acid phosphatase AV Aortic valve ACTH Adrenocorticotrophic hormone AV ADENOCA Adenocarcinoma AV Atrioventricular ADH Antidiuretic hormone (vasopressin) AV Average ADJ Adjacent A & W Alive and well ADM Admission AX Aailla(ry) ADM Admit AX Axi_ial) AFF Afferent AFF Affirmative B Bacillus AF'P Aipha-fetoprotein B Black AG Atrial gallop B Blue AG Antigen B Born AG Argentum (silver, chemical symbol for) B Brother AGL Acute granulocytic leukemia BA Bachelor of Arts A/G RATIO Albumin-globulin ratio BA Barium (chemical symbol for) AGNO a Silver nitrate BA Bronchial asthma AIDS Acquired immunodeficiency syndrome BAS Basal AK(A) Above knee (amputation) BASOS Basophil(s) (granular leukocyte) AKA Also known as BBB Blood-brain barrier ALB Albumin BBB Bundle-I_ranch block ALK PHOS Alkaline phosphatase BBT Basal body temperature ALL Acute lymphocytic leukemia BC Birth control AMA Against medical advice BC Bone comluction AMB Ambulatory BC Buccocervical AML Acute myelogenous leukemia BCC Basal cell carcinoma AMP Amputation B-CELLS Special lymphocytes formed in bone marrow ANAP Anaplastic (derived from bursa of Fabricius) ANAT Anatomy BCG BacillusCalmette-Guerin ANES(TH) Anesthesia, anesthetic BD Bile duct ANT Anterior BE Barium enema ANTE Before B/F Black female A&P Auscultation & percussion BIL Bilateral AP Abdominal perineal BK(A) Below knee (amputation) AP Anteroposterior BM Bone marrow AP Anterior pituitary BM Bowel-movement AP&LAT Anteroposterior and lateral B/M BMR Black male Basal metabolism rate 255
BP Blood pressure DIS, DISCH Disease; Di_ BPH Benign prostatic hypertrophy/hylmrplasla DNA Decayriboaudeic acid BRIM BSC Biological respome modifier Bone scan DO DOA Doctor of Osteopathy Dead oQ 1_O Bilatend salpingo-oophorectomy DOB Date of birth BT Brain tumor DOD Date of death BUN Blood urea nitrogen DOE Dyspuea on eaertion BUS Bartholin's, uethral & Skene's glands DR (Medical) doctor BX BiOlmY DS Discharge DTR Deep m_d
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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
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EXAMPLEE16 MRI CONSULTATIONREPORT N
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HEMATOLOGIC EXAMINATION A hematolog
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Granulocytes or granular leukocytes
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Certain types of disease associated
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EXAMPLE E17 HEMATOLOGY LABORATORY N
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EXAMPLEE18 HEMATOLOGY LABORATORY Na
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EXAMPLE E19 HEMATOLOGY LABORATORY R
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PRACTICAL EXERCISE ANSWERS Example
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Bone Marrow Studies. Examination of
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EXAMPLE E20 Name: Bo Comeaway Hospi
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Example E20 can be abstracted as fo
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Blood Serum Studies Automation and
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Other Laboratory Studies Marrow Aci
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Totalprotein. This test measures th
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SECTION F MANIPULATIVE AND OPERATIV
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SECTION F MANIPULATIVE AND OPERATIV
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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
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The illustrated report can be abstr
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I EXAMPLE F3 REPORT OF CYSTOSCOPY N
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Example F3 is abstracted as follows
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EXAMPLE F4 GASTROINTESTINAL DIAGNOS
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The information described in Exampl
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EXAMPLE F5 SIGMOIDOSCOPY REPORT Rec
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EXAMPLE F6 PROCTOSCOPY REPORT Rec.
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EXAMPLE F7 GASTROSCOPIC REPORT Hosp
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EXAMPLE F8 GASTROSCOPIC REPORT Hosp
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EXAMPLE F9 BRONCHOSCOPY REPORT Hosp
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EXAMPLE FIO BRONCHOSCOPY REPORT Hos
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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
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Example F15: 3/11/91. Expl. Lap.: L
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PRACTICAL EXERCISE The following pa
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These operative reports can be abst
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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
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 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 230 and 231: PRACTICAL EXERCISE ANSWERS Example
Page 232 and 233: EXAMPLE G10 AUTOPSY REPORT IDENTIFI
Page 234 and 235: EXAMPLE G10 (continued) CLINICOPATH
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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
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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 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
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