Text documentation is required to justify coded values and to supplement information not transmitted with coded values. You should be able to abstract your entire abstract based on the text recorded. Just wanted to send out a reminder about exam text. We are seeing a lot of registrars forgetting to include these basic items in their physical exam text.
Most Common Items Missing from Physical Exam Text:
- Physical Exam
- Ethnicity
- Marital Status
- Correct Age at Diagnosis {be sure to note the correct age at dx, don’t rely on physician documentation sometimes the patient had a birthday, record the correct age at diagnosis}
Please review the example below to guide you on what should be documented in the Physical Exam Text Field.
| Text Field | Required Documentation in Field | Example |
| Physical Exam | · Date case became analytic or date of first contract.
· Facility or Location · Class of Case · Demographics: Age, Sex, Race. Ethnicity, Marital Status, · Reason for Admission to Your Facility · Pertinent Findings from Physical Exam, Type and Duration of Symptoms · Vitals: Height, Weight · Past Medical History · Social History: Smoking, Alcohol. Any Exposures to Carcinogens. · Family History: Relation, Type of Cancer |
1/15/2023 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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Text Resources:
- State Specific Text Guidelines
- Facility Text Guidelines
- 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/