California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
In this text field, enter the details needed to describe the information from the pathology or cytology reports.
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.
Text information that supports the Path Report Identifier Data Items (1-5) should be recorded here, identifying each report by using the R1- R5 designation.
Each path report must be identified in the text field as R1 - R5 with R1 referencing Path Report 1, R2 referencing Report 2, etc.
If additional space is necessary, continue the text documentation in the Text - Staging field.
If there is a pathology report, all the Path Report Identifier Data Item fields must be completed. See Path Report Identifier Data Items for further instructions.
If the medical record only includes "hearsay" information or the physician only refers to a report finding, but there is no report in the medical record, do not complete the Path Report fields, but include the information in the text field.
Record dates and names of the operative procedures
Use either a slash (/) or hyphen (-) to separate month, day, and year.
Describe the location of the primary site, sub-site, and/or the laterality of the primary tumor. See Primary Site and Laterality.
Record the histologic diagnosis. See ICD-O Morphology – Histology, Behavior, and Differentiation.
Describe multiple tumors and multiple sites of origin.
Document the extent of disease and stage at diagnosis.
Describe the number of lymph nodes examined and the number positive for cancer.
Determine the method of diagnosis or confirmation.
Identify all specimens examined microscopically.
Record all tumor related gross (non-microscopic) and microscopic cytologic and histologic finding whether positive or negative, and include differentiation.
Record margin status. Including any site specific margins such as circumferential resection margin (CRM) for colorectal primaries.
Staging only by the pathologist is recorded in this field.
Staging by other physicians should be recorded in the Text-Staging field.
If additional space is needed, continue the pathology text in any other available text field and indicate which text field the text is extending to.
For details about microscopic diagnoses, see Diagnostic Confirmation.