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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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- Page 123 and 124: Bilirubin. Bilirubin is a pigment e
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- Page 129 and 130: Proctoscopy, Sigmoidoscopy, and Col
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- Page 133 and 134: Bronchoscopy. Bronchoscopy is the v
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Example F8: 2/26/91. Gastroscopy: A
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162
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164
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EXAMPLE F17 (continued) PROCEDURE C
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HISTOLOGIC EXAMINATION For most neo
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196
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198
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B. The Operative Pathology Report (
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When summarizing the pathology repo
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204
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EXAMPLE G3 continued grossly to wit
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EXAMPLE G4 (continued) left radical
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210
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EXAMPLE G5 (continued) MICROSCOPIC:
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The information which should be abs
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216
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218
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EXAMPLE G7 (continued) 6. Received
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222
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224
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C. The Autopsy (Necropsy; Postmorte
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EXAMPLE G10 (continued) HNAL PATHOL
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230
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232
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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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240
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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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260
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Carcinoma-in situ CIS Enlargexl ENL
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Occupational therapy OT Radioactive
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268
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AJCC American Joint Committee on Ca
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GRATEFUL MED A system for simplifyi
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274
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276
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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