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

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SECTION E CLINICAL EXAMINATIONS: PHYSICAL, RADIOLOGIC, DIAGNOSTIC NUCLEAR MEDICINE, OTHER IMAGING, AND HEMATOLOGIC 27
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 34: SECTION E CLINICAL EXAMINATIONS: PH
Page 38: Example E1 can be abstracted as fol
Page 42: Example E2 can be abstracted as fol
Page 45 and 46: RADIOLOGIC EXAMINATIONS USING CONTR
Page 48: EXAMPLE E3 Name: Mr. Noah Reprieve
Page 52: EXAMPLE E4 Name: Sonya Heare Hospit
Page 56: EXAMPLE E5 Name: Mar)/Secondchance
Page 60: EXAMPLE E6 DEPARTMENT OF RADIOLOGY
Page 64: EXAMPLE E7 Name: Nancy Etta Feather
Page 68: EXAMPLE E8 Name: Lottie Herring Hos
Page 72: EXAMPLE El0 Name: Ira Sickmann Rec.
Page 76: COMPUTERIZED (AXIAL) TOMOGRAPHY (CT
Page 80 and 81: The CT scan report can be abstracte
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Figure 1. DIAGNOSTIC IMAGING- NUCLE
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EXAMPLE El3 THE DIVISION OF NUCLEAR
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Examples E12-E14 should be abstract
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EXAMPLE El5 MAGNETIC RESONANCE IMAG
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Examples El5 and El6 are abstracted
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Word Element Meaning a. hemat(o)log
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NORMAL BLOOD VALUES The values for
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Example E18 simply records the work
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Bilirubin. Bilirubin is a pigment e
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Proctoscopy, Sigmoidoscopy, and Col
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Bronchoscopy. Bronchoscopy is the v
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Example F8: 2/26/91. Gastroscopy: A
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EXAMPLE F17 (continued) PROCEDURE C
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HISTOLOGIC EXAMINATION For most neo
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B. The Operative Pathology Report (
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When summarizing the pathology repo
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EXAMPLE G3 continued grossly to wit
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EXAMPLE G4 (continued) left radical
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EXAMPLE G5 (continued) MICROSCOPIC:
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The information which should be abs
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EXAMPLE G7 (continued) 6. Received
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C. The Autopsy (Necropsy; Postmorte
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EXAMPLE G10 (continued) HNAL PATHOL
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EXAMPLE Gll (Continued) DEPARTMENT
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EXAMPLE Gll (Continued) DEPARTMENT
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EXAMPLE G11 (Continued) DEPARTMENT
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CYTOLOGY AND ITS PROCEDURES Cytolog
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lII.A.2b III.A.3 High grade squamou
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BP Blood pressure DIS, DISCH Diseas
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NED No evidence of disease POD Post
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Carcinoma-in situ CIS Enlargexl ENL
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Occupational therapy OT Radioactive
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AJCC American Joint Committee on Ca
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GRATEFUL MED A system for simplifyi
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Biographical information (Cont'd) R
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Cytologic E_minations (Cont'd) Spin
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-graph (definition), 29 Graphic rep
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Medication record, 9, 10 Metamyeloc
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Progress notes, 9, 10 Doctor's orde
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Ultrasonogram, 45 Ultrasonography,
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Index of Examples (Cont'd) Example
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