California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
In order to completely capture all aspects of a patient’s surgical treatment, it is necessary to review multiple sources. This instruction directs abstractors on where to obtain information regarding surgery.
To ascertain exactly what procedures were performed, read the operative and pathology reports thoroughly. Do not depend on the title of an operative report, because it might be incomplete.
If the operative report is unclear about what tissue was excised or the operative and pathology reports contain different information, use the pathology report unless there is reason to doubt its accuracy.