California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
Enter findings from operative procedures performed during the diagnosis or treatment of the cancer.
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 pertinent observations of the surgeon (what is seen/felt/palpated) during the surgical procedure.
Record pertinent positive and negative results of diagnostic surgical procedures, such as biopsies, dilation and curettage (D & C), and laparotomy, as well as definitive surgery findings entered under treatment, See Sections VI.2.1 through VI.2.9. Important information to include is:
Record dates and names of the operative procedures
Use either a slash (/) or hyphen (-) to separate month, day, and year.
Location of the primary tumor
Tumor Size
A description of the primary tumor and whether or not multi-focal
Extent to which the tumor has spread
Residual tumor size
Involvement or non-involvement of lymph nodes
Enter "none" if no operations were performed