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

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Example E6 might be abstracted as follows: 2/17/91. Thermograms, Bilat.: WNL. 0 Comment: Note R/O means "Rule out" breast cancer. It is a directive, not a diagnosis. An x-ray report may result from a request <strong>for</strong> consultation from another department in the hospital. The radiologist will then read the x-ray film and prepare an x-ray consultation report. A request <strong>for</strong> consultation is illustrated on the next page (Example E7). Abstract what you think is pertinent in the report and then compare with the suggested abstraction on page 61. 57
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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
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 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
Page 82: Figure 1. DIAGNOSTIC IMAGING- NUCLE
Page 86: EXAMPLE El3 THE DIVISION OF NUCLEAR
Page 90: Examples E12-E14 should be abstract
Page 94: EXAMPLE El5 MAGNETIC RESONANCE IMAG
Page 98: Examples El5 and El6 are abstracted
Page 101 and 102: Word Element Meaning a. hemat(o)log
Page 103 and 104: NORMAL BLOOD VALUES The values for
Page 105 and 106: 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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