IV.1 Text - Diagnostic Procedures Performed

Text Documentation Instructions:

• Report results for all analytic cases and for autopsy only (class 38) cases.

• Reporting diagnostic procedures is optional for non-analytic cases; however record a brief statement of the patient's history and the reason for the present admission in the Physical Exam text area.

• Coded fields must be supported by text documentation on the abstract.

• Information which does not require supporting text:

• Date of Birth (DOB) (unless the patient is 100 years of age or older). See Age at Diagnosis.

• Social Security Number (SSN)

• Medical Record Number (MRN)

• Comorbidities

• Secondary Diagnosis

• Record text in a consistent, organized manner.

• 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.

• Do not leave field blank. Record “None”, NR, or NA when information is missing from the medical record or there is not pertinent information.

• Enter text documentation in the following order, chronologically by date:

• Enter date

• Use either a slash (/) or hyphen (-) to separate month, day, and year.

• • Name of Exam

  • Results and other pertinent cancer related findings (negative as well as positive)

• Enter text documentation that supports the following items:

• 1. • Location: Refers to where the tumor is located in the primary site, such as lobe, quadrant, etc.

     • Tumor Size: Refers to the size of the tumor. For instructions, see Tumor Size.

     • Extension: The extent or growth from the primary site into other tissue or organs.  

     • Lymph Nodes: The involvement and count of regional lymph nodes involved.

     • Metastasis: The involvement of distant tissue, structures, or lymph nodes.

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