California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
Information about cancer cases is reported to the CCR in the form of abstracts, which summarize pertinent information about individual cases. (Refer to Appendix U - Data Items and Their Required Status). If in doubt about how certain fields should be completed, the regional registry should be contacted.
Whatever reporting software is used, rules for entering data must be followed precisely.
The text summaries required for the sections on diagnostic procedures and treatment should be as concise as possible.
Every required data item must be completed, and the entries must be accurate, concise, and clear.
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