California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
Enter findings from the physical examination performed by the physician.
Use standard medical abbreviations when possible. See Appendices M.1 and M.2 for common acceptable abbreviations.
Use phrases not complete sentences. Separate phrases using either periods (.) or semi-colons (:).
Avoid using only uppercase/capitals in text documentation.
Record both the information and the source of the information.
Example: Race (white per face sheet)
The following demographics may be entered in either the physical exam or remarks text fields:
Age
Include text verification in the remarks text field when the patient is 100 years or older.
Race
Include text verification for the race of patient in the remarks text field, when coded as "Other" or if there is conflicting race information. See Race and Ethnicity.
Hispanic Origin
Sex
Record the date of the patient's physical examination.
Use either a slash (/) or hyphen (-) to separate month, day, and year.
Record any pertinent positive and negative results, including:
Location of the primary tumor and whether or not it is multifocal
Tumor Size
Extent to which the tumor has spread
Involvement of lymph nodes.