You should be able to abstract a case from the text you have documented. Be sure to follow your specific facility guidelines and/or State requirements for text. Below are some areas of text that often get overlooked, please be mindful and don’t forget the CYA policy of text documentation, Cover Your Abstracting or Care (about) Your Auditor, good text can help us out so much.
Refer to 2024 Omega Cancer Registry Text Documentation Guidelines for more information… Below is a table to highlight areas of text most often forgotten & some tips.
| NAACCR # /Text Field | Most often Forgotten Piece of Text/ Tips to Remember | Examples of Thorough Text |
| # 2520 Physical Exam | · Physical Exam-Note information about primary tumor, lymph nodes, splenomegaly, comorbidities, etc.
· Demographic such as Age, Sex, Race, Ethnicity-Watch overuse of bogus abbreviations. Only NAACCR-approved abbreviations should be utilized (see Appendix G). · Marital Status-if collected by your State · Height/Weight/Smoking/Family-if required by your State · History of previous tumors to substantiate Sequence # · If information is missing from the record, state that it is missing. Example: No DRE available in EMR
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1/15/2024 diagnosed Hospital XYZ. All Treatment Done Elsewhere Hosp ABC. Class of Case 00.
70 YO non-Hispanic white married male presented to Hospital XYZ for prostate bx after elevated PSA. After positive biopsy, Pt transferred care to Hospital ABC. PE: Diffuse nodularity in left lobe of prostate. No palp LNS(s). Height 5’10”. WT 180 LB. PMH of COPD, SHX – current cigarette smoker 1 PPD x 50 yrs. Denies alcohol use. Vietnam Vet and shipyard worker. FHX – father with lung cancer, mother w/ breast cancer.
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| #2570 Path Text | · Comments/Addendums-these are often missing from text, but the information is often vital, be sure to note in text
· Name of Lymph Nodes removed-note the station, name, or region the nodes came from · Be sure to check Gross section of path report as well, sometimes items such as tumor size, distance from CRM noted in the Gross · Don’t forget the synoptic info
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2/5/2024 (Hospital XYZ) – Path Acc # ‐ LUL wedge resection: LUL 3.5cm Invasive Adenocarcinoma, acinar predominant, G2 moderately differentiated pT2a pN0 6 Nodes (-) [Three from Level 5, One from Level 6, Two from Level 7] Margins (-), LVI (-) No visceral pleural involvement PDL1+
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| #2550 Lab Test Text | · Note the Tumor Markers Dates/Names/Results/ Whether elevated or range
· Note which crucial Tumor Markers, Lab test to substantiate SSDIs are Missing or Not Done |
4/12/2024 (Hospital XYZ) ER 90%+ Strong Intensity, PR 0% Negative, HER2 neg by IHC method
4/12/2024 (Hospital XYZ) PSA 5.3 (elevated) 4/12/2024 Pre-op CEA Not Done 4/12/2024 ALK Rearrangement, EGFR Mutational Analysis -Not Available/Not Done 4/12/2024 LDH 153 U/L {range 87-241} |
| #2880 Site Text | · Make sure your text substantiates site, laterality if required, maybe tumor size
· Prefer text to substantiate the code as opposed to only documenting the actual code C504RUOQ Breast
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Breast RUQ 3.5 cm
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| #2590 Histology Text | · Grade or Differentiation, Histology, Include Special Grade if Required by Site
· Prefer text to substantiate the code as opposed to only documenting the actual code 8140 Adenocarcinoma
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PD infiltrating Ductal ca, Nottingham 9 |
| #2690 Place of Dx Text | · Make it easy to decipher, Enter Date, Facility or Location, How diagnosed
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1/15/2024 (Hospital XYZ) breast bx |
| #2530 X-ray/Scan-Text | · Pertinent Results to Support Primary Site & Stage
· Include adenopathy, or if nodes are WNL or not mentioned in the EMR. Include ascites, pleural or pericardial effusion, etc. (Do not abstract from “impression” only, use the entire report.)
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1/15/2024 Hospital XYZ, CT w/wo contrast: RUL lung nodule 3.5 cm. Hilar adenopathy, largest node 1.8 cm. No mention of mediastinal nodes in report. No pleural effusion. |
| #2540 Scope Text | · Pertinent results-primary site, extent of tumor spread, satellite lesions), clinical assessment, positive/ negative results
· Was bx done
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1/15/2024 Endoscopy Center XYZ, colonoscopy – partially obstructing circumferential mass in sigmoid colon w/ bx. |
| #2560 Op Text | · DO NOT DUPLICATE THE SAME EXACT INFO IN THIS FIELD IN SURGERY TEXT FIELD
· Operative Text is to document what was found during the operation |
1/17/2024 Hospital XYZ, Dr X, Right hemicolectomy. No other disease noted in abd.
1/15/2024 Hospital XYZ, Dr South, Hysterectomy, BSO, tumor debulking. Seeding on diaphragm noted, less than 2 cm. not removed. Residual seeding in cul-de-sac. |
| #2610 Surgery Text | · DO NOT DUPLICATE THE SAME EXACT INFO IN THIS FIELD IN OPERATIVE TEXT FIELD
· Surgery Text is to substantiate the surgery coding. · If surgery not done, note whether not recommended, recommended unknown if done, refused, contraindicated, etc. and where that was decision was made |
1/17/2024 Hospital XYZ, Dr X, Right hemicolectomy. No nodes removed
1/17/2024 Hospital XYZ, Dr X, Right hemicolectomy. 24 regional nodes removed
1/15/2024 Hospital XYZ, Dr South, Hysterectomy, BSO, tumor debulking. Retroperitoneal nodes, Para-aortic nodes removed
1/15/2024 Hospital XYZ- Surgery not recommended, recommended unknown if done, refused, contraindicated etc.
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| #2600 Staging Text | · Include info to support:
· AJCC Stage · Summary Stage · EOD if applicable · Note who staged the case (Physician or ODS-enter supporting documentation) *Pathologist cannot stage the case
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Clinical: Med Onc- cT1 cN2 pM1c Stage IV
ODS cT2a (1.8cm +Atelectasis) cN2 (Mediastinal Nodes) pM1c(+Bx Liver-mult liver mets seen on CT) Stage IVB Path: ODS- cT2a cN2 pM1c Stage IVB Summary Stage: Distant EOD Extension: (1.8cm+ Atelectasis) EOD Regional nodes: Mediastinal Nodes EOD Mets: Multiple Liver Mets |
| #2620 Radiation (Beam) Text | · Often forgotten is the text to substantiate modality/planning technique
· Include where the radiation was done · Text should also substantiate Reason for No Radiation |
1/1/2024 – 2/1/2024 Hospital XYZ, per Med Onc, Adjuvant (or neoadjuvant) 6mv IMRT to Right breast for 5040 cGy in 33 fx over 30 elapsed days. 2/1/2024 – 2/7/2024 6mv IMRT Boost to rt breast for 1000 cGy in 5 fx over 5 elapsed days.
1/15/2024 Hospital XYZ-Radiation not recommended, recommended unknown if done, refused, contraindicated etc. |
| #2630 Radiation (Other) Text | · This field is used to substantiate radiation treatment other than beam
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2/15/2024 Hospital XYZ ‐ Rad Onc Note-radioactive seed implant, radioisotopes (I‐131) |
| #2640 Chemo Text | · Note All Drugs given, not just Regimen
· Note whether recommended, not recommended, refused, contraindicated, expired, or given etc. · Note where recommendation given/refused to substantiate Chemo done at this facility · Note whether adjuvant, neoadjuvant, or both etc.
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1/5/2024 – 4/7/2024 Medical Oncology Office XYZ, Med Onc Note, adjuvant Carboplatin and 5fu completed 5/6 planned cycles due to neutropenia.
1/15/2024 Hospital XYZ- Chemo not recommended, recommended unknown if done, refused, contraindicated etc.
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| #2650 Hormone Text | · Note whether recommended, not recommended, refused, contraindicated, expired, or given etc.
· Note where recommendation given/refused to substantiate Hormone done at this facility · Note whether adjuvant, neoadjuvant, or both etc
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1/5/2024 Medical Oncology Office XYZ-Med Onc Note, adjuvant tamoxifen for planned 5+ yrs. Pt self d/c on 5/1/17 due to hot flashes, refused further horm.
1/15/2024 Hospital XYZ-Hormone not recommended, recommended unknown if done, refused, contraindicated etc. |
| #2660 Immuno/ BRM Text | · Note whether recommended, not recommended, refused, contraindicated, expired, or given etc.
· Note where recommendation given/refused to substantiate Immuno/BRM done at this facility · Note whether adjuvant, neoadjuvant, or both etc
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1/5/2024 Medical Oncology Office XYZ- Med Onc Note, Neoadjuvant until surg and resumed adjuvant tx on 6/1/17 w/ Herceptin, planned to continue for 1 full year.
1/15/2024 Hospital XYZ- Immuno/BRM not recommended, recommended unknown if done, refused, contraindicated etc. |
| #2670 Hem/Other/Pall Rx Text | • Don’t forgot to code Palliative/Transplant/ Other treatment
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1/1/2024 Hospital XYZ- Primary Care Physician Consult Note, Phlebotomy ongoing.
1/1/2024 Hospital XYZ-Palliative XRT to Spine, pain meds due to cancer pain
1/1/2024 Referred for bone marrow transplant at Hospital XYZ, felt to be a likely candidate for autologous stem cell transplant after treatment for hepatitis c |
Resources:
- NAACCR Abbreviations and Acronyms Recommended Abbreviations for Abstractors https://apps.naaccr.org/data-dictionary/data-dictionary/version=24/chapter-view/
- NCRA Informational Abstracts (These site-specific abstracts provide an outline to follow when determining what text to include.) http://www.cancerregistryeducation.org/rr
- AJCC Cancer Staging Manual-Registry Data Collection Variables (Each Chapter in the AJCC has a list of Registry Data Collection Variables which should be documented in text if available.)
- Site-Specific Data Item (SSDI) Manual https://www.naaccr.org/
- College of American Pathology Cancer Protocol Templates https://www.cap.org/