California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
Document X-Ray/Scan findings in this text field to capture relevant positive and negative findings on imaging or scans performed.
Use standard medical abbreviations when possible. See Appendices M.1 and M.2 for common acceptable abbreviations.
Enter "none" if no X-rays or scans were performed.
Use phrases not complete sentences. Separate phrases using either periods (.) or semi-colons (:).
Avoid using only uppercase/capitals in text documentation.
Enter findings from the X-rays, computerized axial tomography (CT or CAT scans), magnetic resonance imaging (MRI), echosonography, and other imaging used to diagnose or stage the cancer in the following order:
Record dates of the image
Use either a slash (/) or hyphen (-) to separate month, day, and year.
If there are multiple procedures, record in chronological order
For multiple procedures performed on the same date, record the date once and separate procedures with a period or semi-colon
Name of exam (i.e. CT Abdomen/Pelvis), MRI Brain)
Enter the findings, positive and negative results, including:
A description of the primary tumor and whether or not it is multi-focal
Location of the primary tumor
Tumor size
Laterality
Extent to which the tumor has spread:
Spread within the organ of origin
Invasion to other tissues or adjacent organs and lymph nodes by direct extension
Involvement or non-involvement of lymph nodes
Distant disease or metastasis
Involvement of distant sites including distant lymph nodes