Case Text

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In accordance with new CDC/NPCR requirements, KCR began requiring text documentation on all new cases diagnosed January 1, 2001 and after. The documentation must include explanations regarding the history and physical, diagnostic procedures, surgeries performed surgical findings and place of diagnosis.

Text is needed to justify codes selected for specific data elements and to allow for the recording of information that is not coded at all. It is used by the central registry for quality control of the data and to assure that the data meets the standards of ACoS, NAACCR, NCDB, SEER, and NPCR.

It also is utilized to answer questions which arise during the editing and consolidation process performed at the central registry, thus improving the accuracy and timeliness of that process as well. The best code(s) from all sources can generally be selected when the supporting text is sufficient to help verify the decision.

Through more complete documentation in the text fields, it is expected that fewer cases will need to be returned to the hospital for further review and/or clarification and that error rates in data abstraction will be reduced.

TEXT FIELDS

GENERAL INSTRUCTIONS

1. Select the category from the previous page which is the most logical to you in recording the required information. Record the information only one time even though multiple categories may apply. As an alternative, all information may be documented in the Miscellaneous/General Text field. The information, however, will need to be labeled with the appropriate text field heading.
2. Be brief. Don’t record in full sentences.
3. Use standard medical abbreviations (see APPENDIX I) when possible to save space, i.e., CXR-chest x-ray; LN-lymph node; LAD-lymphadenopathy.
4. Record text information on all analytic cases. For non-analytic cases, record all dates and cancer directed therapies regardless of where received at a minimum.
5. Record exact terminology from the source document to justify your codes. Be certain to include ambiguous terminology where pertinent to the information coded, i.e., "most likely" primary lung cancer.
6. Document both positive and negative findings, i.e., H & P: peau d’orange skin; CT: neg LAD.
7. Enter in chronological order the results of diagnostic examinations and cancer directed surgeries. Record the date first, then name of procedure, the results and pertinent information. (New in NAACCR)
8. Enter additional staging information in the Staging Text field that is not documented in the other text fields.
9. Record in the Miscellaneous/General Text fields information that is overflow from a more specific text field and other pertinent information for which there is no designated field. For overflow information, indicate the name of the field being extended and then the additional pertinent information.
10. Date the open text entries in the Miscellaneous/General Text field at the beginning of the entry, including the month and year only. Record your initials at the end of the entry.

Specific Data Item Instructions

Document the following information as indicated in an appropriate text field category.

1. Sequence Number - Note any history of a previous cancer with emphasis on the most specific site identified and the laterality when multiple primaries involve paired organs. Record date previous cancer diagnosed. Indicate if estimated.
2. Topography
   1. Document the exact anatomic location of the primary tumor including lobe, quadrant, etc. as well as laterality if a paired organ.
   2. Include any ambiguous terminology used to describe the primary site.
   3. Record statements that rule out specific sites when patient has multiple cases of cancer, one of which is an unknown primary.
   4. Note unusual topography/histology combinations (i.e., pathologist’s diagnosis is endometrioid cancer of uterus - ICD-O-3 shows C56.9 ovary).
3. Histology and Grade
   1. Record the exact wording used in the Final Pathologic Diagnosis on the pathology report to support the histology code.
   2. If the final histologic diagnosis is an NOS term and a more definitive histology is found in the body of the report or in a special NOTE or COMMENT section, indicate from which section the histologic diagnosis was coded.
   3. When a more definitive diagnosis is obtained from a supplementary document such as an immunohistochemistry report or pathologic consultation, note the source document name which provides the final diagnosis.
   4. Specify the tumor grade exactly as recorded on the pathology report, i.e., II/III (new in NAACCR).
4. Diagnosis Date
   1. Document the date, place, source document, and exact wording of the first occurrence of a positive cancer diagnosis. Remember to include any ambiguous terms used in making the diagnosis.
   2. Record the age at diagnosis
5. Diagnostic Confirmation
   1. Explain when codes 6, 7 or 8 are utilized, i.e., patient refused further workup. Remember the confirmation field covers the entire history of the patient’s cancer from diagnosis to death and should be updated to a lower code whenever appropriate.
6. Tumor Size
   1. Document source of the most definitive size. See Collaborative Staging Manual and Coding Instructions or EOD (for pre-2004 cases) for priority of documents to use in coding this element.
   2. Record all dimensions of the primary tumor; specify the unit of measure given including comparative descriptions such as "golf ball-sized" if applicable.
   3. Note such descriptions as diffuse, widespread, entire circumference.
   4. Document instances where a tumor contains both invasive and in-situ components and only the size of the entire lesion is noted.
7. Collaborative Staging items
   1. SEER Extent of Disease (for pre-2004 cases)
   2. TNM Classification & Grouping
      1. Record date, name of exam and any positive or negative findings which support the extent of disease coded for each of the staging systems above. Enter details regarding direct extension to other organs or structures, presence of satellite lesions/nodules and location. Be sure to include any ambiguous terminology used to indicate a positive finding.
      2. Note disagreement with TNM staging between registrar and physician.
      3. Document abstracting "rules" when pertinent, i.e., TNM chapter does not include sarcomas.
      4. Enter notation when staging supplied by another facility’s registrar/doctor.
8. Regional Nodes Positive and Examined
   1. List exact name(s) of lymph nodes and corresponding number removed from pathology report. Include information regarding laterality of nodes involved.
9. Surgery at Primary Site
   1. Enter the exact wording of the operative procedure performed. Include names of all organs removed "en bloc" and specify as such.
10. Surgical Margins
    1. Document the exact wording from the path report which supports the code selected. Indicate whether this represents a gross or microscopic description.
11. Scope of Regional Lymph Node Surgery
    1. List date, exact name(s) of lymph nodes, corresponding number removed and laterality for each separate surgical procedure performed.
12. Surgery at Regional/Distant Sites
    1. Record the specific organs/tissues removed (partial or total) during the surgical procedure.
13. Chemotherapy Code
    1. Note the exact names of agents administered.
14. Other Therapy Codes
    1. Describe in words the procedures performed and/or drugs utilized.
15. Date of Last Contact or Death
    1. Document source of date of death, i.e., obituaries, expired at your facility, quarterly death list, Social Security Death Index (SSDI), KCR Vital Status Report, other health care facility.
16. General Remarks
    1. Note any and all changes requested by KCR, including the date of the request or the name and date of the document from KCR which requests the change.
    2. Explain any unusual circumstances which impacted the manner in which the case was coded, i.e., an unusual primary site for a particular histologic type verified by an outside institution, i.e., the Armed Forces Institute of Pathology (AFIP).
    3. Enter reason why no therapy administered if known.
    4. Should patient refuse further therapy, document therapy type and refusal.
    5. Specify any dates which are estimated.
    6. Record recommended treatment(s), that is, unknown if given.
    7. Indicate information which has been coded from a source other than the medical record and what the source was, i.e., verbal information from another registrar.