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

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SEER Program Self InstructionalManual for Cancer Registrars Abstracting a Medical Record: Patient Identification, History and Examinations Book Five Second Edition U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service
SELF-INSTRUCTIONAL MANUAL FOR CANCER REGISTRARS Book 5 - Abstracting a Medical Record: Patient Identification, History, and Examinations Originally Prepared for the Louisiana Regional Medical Program Under the Direction of: C. Dennis Fink, Ph.D., Program Director, HumRRO Robert F. Ryan, M.D., Technical Advisor, Tulane University Revised by: SEER Program Cancer Statistics Branch National Cancer Institute Editor in Chief: Evelyn M. Shambaugh, M.A., CTR Cancer Statistics Branch National Cancer Institute Assisted by Self-Instructional Manual Committee: Dr. Robert F. Ryan, Emeritus Professor of Surgery Tulane University School of Medicine New Orleans, Louisiana Mildred A. Weiss Los Angeles, California Mary A. Kruse Bethesda, Maryland
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:
Example E4 can be abstracted as fol
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
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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 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 178 and 179:
Page 180 and 181:
Example F15: 3/11/91. Expl. Lap.: L
Page 182 and 183:
PRACTICAL EXERCISE The following pa
Page 184 and 185:
Page 186 and 187:
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:
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
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