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

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TABLE OF CONTENTS BOOK 5: ABSTRACTING A MEDICAL RECORD: PATIENT IDENTIFICATION, HISTORY, AND EXAMINATIONS Page Section A--Objectives and Content of Book 5 .................................. 1 Section B--The Composition and Organization of a Medical Record ................. 5 Section C--Abstracting a Medical Record: What, When, and How to Abstract ......... 13 Section D--Diagnostic Procedures: General Description .......................... 23 Section E--Clinical Examinations: Physical, Radiologic, Diagnostic Nuclear Medicine, and Hematologic ................................................. 27 Section F--Manipulative and Operative Procedures ............................. 121 Section G--Pathological Examinations ....................................... 191 Common Abbreviations ................................................... 2.55 Common Symbols ....................................................... 267 Acronyms of Organizations Concerned with Cancer .............................. 269 The Automated Cause Coding System ........................................ 272 Acronyms for Study Groups ............................................... 273 Selected Bibliography .................................................... 275 Index ................................................................ 277
ACKNOWLEDGEMENTS The variety of medical specialties with their ever increasing use of new techniques has made it necessary to seek the advice of specialists in the various areas of medical diagnosis and treatment to ensure adequate and accurate descriptions of these techniques for this Instructional Manual. In every instance the physicians to whom we turned have extended their assistance with the greatest good will. In particular I would like to mention: Dr. John L. Doppman Chief, Department of Radiology Clinical Center National Institutes of Health Dr. Harvey R. Gralnick Head of Clinical Pathology Clinical Center National Institutes of Health Dr. Kenneth R. Hande Laboratory of Clinical Pharmacology National Cancer Institute Dr. A. Eric Jones Nuclear Medicine Clinical Center National Institutes of Health Much effort has gone into making the presentation of the examples interesting as well as realistic. There is a great deal to be learned in this book, and we have tried to make it stimulating and, perhaps, amusing with the play on names. Evelyn M. Shambaugh Editor in Chief
Page 2 and 3: SEER Program Self InstructionalManu
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
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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
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
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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
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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
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
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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:
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
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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
Page 274 and 275:
ACRONYMS FOR ORGANIZATIONS CONCERNE
Page 276 and 277:
WORLDWIDE ORGANIZATIONS IACR Intern
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ACRONYMS FOR STUDY GROUPS The follo
Page 280 and 281:
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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