California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
In the Scopes section of the abstract, record information for all scopes performed as part of the initial work-up of diagnosis.
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.
Enter the date and type of procedure performed, such as laryngoscopies, sigmoidoscopies, mediastinoscopies, colonoscopies, and other endoscopic procedures.
Use either a slash (/) or hyphen (-) to separate month, day, and year.
Record any pertinent positive and negative results, including:
A description of the primary tumor and whether or not it is multifocal
Tumor Size
Extent to which the tumor has spread
Involvement of lymph nodes
Include mention of biopsies, washings, and other procedures performed during the examination. All results obtained from these procedures must be entered in the Text – Pathology Section.
Enter "none" if no endoscopic examination was performed.