VIII.1 Text - Remarks

Coding Instructions:

• 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 both the information and the source of the information

Example: Race (white per face sheet)

• Indicate the name of the field being extended and enter the overflow information.

• The following required data must be recorded in the Remarks section:

• Other tumors. See Other Tumors/Primaries.

• Parent or guardian of a child whose case is being reported. (Information about the parent is also entered in the Follow-Up Contact #1 area. See Follow-Up Contacts 2 - 6.

• The following demographics may be entered in either the physical exam or remarks text fields:

• Age

• Include text verification in the remarks text field when the patient is 100 years or older.

• Race

• Include text verification for the race of patient in the remarks text field, when coded as "Other" or if there is conflicting race information. See Race and Ethnicity.

• Hispanic Origin

• Sex

• Height, Weight

• Smoking information to support tobacco codes

• Supplemental information, which cannot be coded numerically but may be useful to clarify special circumstances or situations.

• Patient moved to live with family and will receive additional treatment in another state.

• Record other pertinent information for which there is no designated field.

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