Module 3: Abstracting

This module consists of seven units. Units 3.1-3.6 demonstrate that certain information is basic to any cancer registry abstract. Ideas for navigating through a medical record and locating pertinent information are provided. Unit 3.7 provides a list of ambiguous terms to be used when determining the reportability of a case.

After completing this module, cancer abstractors will be able to:

Locate patient demographic information
Locate diagnosing information
Locate cancer information
Locate extent of disease information
Locate treatment information
Be able to abstract pertinent information from a medical record
Be able to provide summarized text documentation for the coding of diagnostic procedures, findings and treatment information
Be able to recognize ambiguous terms considered as diagnostic of cancer, as well as, a list of terms not considered as cancer

Module 3 Units:

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Abstracting module was borrowed in part from note pages of a PowerPoint presentation The Art of Abstracting by Susan Van Loon, RN, CTR.

Unit 3.1: Abstracting Hints

Each healthcare facility has its own procedures for organizing a medical record. However, medical records have certain characteristics in common. Usually, a record will be organized with the latest admission located at the front of the record. Most information includes patient identification, biographical information, medical history, physical exam, summary sheets and reports pertinent to the malignancy. Abstracting should be done from the actual reports in the record and not from the point of view of the attending physician.

A separate abstract is prepared for each unrelated malignancy.

It is acceptable to change data items such as primary site, histology, and stage, when information about the original diagnosis becomes more complete. If information has been added to the patient's medical record that was not available at initial diagnosis or at discharge, it is the practice to accept documentation about the case based on the latest or most complete information. The information must be supplementing the original diagnosis and not be based on changes as a result of tumor progression.

It is usually not beneficial to abstract a case immediately upon patient discharge from the healthcare facility; especially if cancer directed treatment has not been completed. Accepted practice allows that cases be abstracted within six months of the date of diagnosis. This offers the opportunity for all pertinent diagnostic and treatment information to be collected in the medical record.

Before abstracting cases, the cancer registrar should:

Be well acquainted with medical terminology and anatomy and physiology
Understand the composition and organization of the medical record
Determine whether a case is reportable

Getting Started

Review the medical record for clues

Face Sheet
History & Physical (H&P)
Imaging Reports
Cytology Reports
Pathology Reports
Surgery Reports
Consult Reports
Discharge Summary

Note: An abstract is a composite of information taken from multiple sources. Use as many of these reports as possible to obtain complete and accurate information. Unless no other reports are available, do not use the Discharge Summary as the sole source of information.

Unit 3.2: Face Sheet/History and Physical Face Sheet

The face sheet contains pertinent patient information, such as:

Name
Use the full name - avoid use of initials, if possible
Use a married woman’s first name – do not use her husband’s first name
Example: Mrs. Jane Smith not Mrs. John Smith
Social Security Number
Date of birth:
Record month, day and year
Age at initial diagnosis for the reported cancer
Place of Birth:
Record state or country
Race – if not on the face sheet, it may be found in the H&P or Nurse’s notes
Spanish/Hispanic Origin
Gender
Marital status
Address:
Record the street, city and zip of current residence
Use the patient’s residence, not the patient’s billing address
Occupation/Industry:
Use specific occupation/industry information, such as Carpenter/Construction
Do not record RETIRED.
If unknown, then record UNKNOWN.
Hospital Medical Record Number

History & Physical (H&P)

The H&P contains:

Findings relative to various body regions
Important diagnostic statements
Procedures planned for the patient such as, x-rays, scopes, lab tests, etc.
Record any pertinent information related to the malignancy.
Example: Mass in left breast and palpable lymph node in left axilla.

Unit 3.3: Imaging

X-rays/Scans/Scopes

Imaging reports contain:

Pertinent findings about the primary tumor and metastatic sites
Record the date, type of x-ray, scan or scope.
Record all pertinent findings whether it is the primary site, extension or information about metastasis.
Be sure to read the whole report.
Be brief, highlight important information only.
Most pertinent information can be found in the final assessment, the final impression, or the final diagnosis; however, some important information can be found in the body of the report.

Examples:
02/05/05 Ultrasound of abdomen-mass lesion, superior portion of the left kidney
05/29/05 Chest x-ray negative for cancer
09-01-05 Bronchoscopy – bronchogenic ca, tumor involving RUL
10/3/05 Liver scan-abnormal. consistent with a central lesion, possible mets.

Unit 3.4: Specimen Reports

Pathology/Bone Marrow/Cytology Reports/Laboratory Reports

Speciment Reports

Speciman reports contain:

Pertinent findings with respect to the malignancy and metastatic sites.

Pathology Reports

Pathology reports contain very important information that may:

Identify the primary site
State the tumor size in the gross section or final diagnosis
State structure and organ involvement
State lymph node involvement
State the extent to which the disease has spread
State surgical margin involvement
State Tumor Marker results
Record the date and pathology number
Record the name of the procedure performed
Record the location of the primary site
Record the size of the tumor
Record the histologic (cell type) diagnosis, including grade (differentiation)
Record the extent of disease within the primary site and beyond
Record the number of lymph nodes removed and number of lymph nodes involved with the disease
Record the tumor markers. For example: PSA levels for prostate cancer and CEA levels for colorectal cancer.

Bone Marrow Aspirations

Record the date and report number
Record the malignant diagnosis such as leukemia, metastasis, or any pertinent comment.
It is not critical to abstract all of the actual lab values.

Cytology Reports

Record the date and cytology number
Record the results of brushings, washings, thoracentesis, and paracentesis with a cancer diagnosis.
- For example: 09-01-05 Fine Needle Aspirate (FNA) of pleural effusion returns as positive for malignant cells.

Unit 3.5: Surgery and Other Treatment

Cancer directed treatment is any procedure that modifies, controls, removes, or destroys cancer tissue.

First course of treatment includes all methods of cancer directed therapy documented in the treatment plan and administered to the patient before disease progression or recurrence. Treatment may include multiple modalities. The time frame for first course of treatment may cover a long period of time e.g. a year or more. No therapy is a treatment option that occurs if the patient refuses treatment, the family or guardian refuses treatment, the patient dies before treatment starts, or the physician recommends no treatment be given.

Treatment Information

Treatment information may be located in:

Surgical report
Pathology report
Radiation therapy records
Progress notes
Physician order sheets
Medicine sheets
Discharge notes

Surgery Reports

Report the date of the surgery and name of the procedure.
Report the primary site, tumor size, lymph node involvement and metastasis.
Report the spread of disease on tissues that were not excised.

Note: If there is conflicting information on the reports, please use the following hierarchy to determine the best information:

Pathologic information takes precedence over operative information
Operative information takes precedence over information from imaging reports
Information from imaging reports takes precedence over the physical exam.
Example: If the imaging report states the tumor size is 3cm, but the pathology report states it is 2cm, then record tumor size as 2cm. If the physical exam states the tumor size as a 2cm lesion, but the imaging states it is 3cm, then record the tumor size as 3cm.

Other Treatment – Chemotherapy, Hormone therapy, Radiation therapy, Biological Response Modifiers (BRM), and Other therapy

Report the dates
Report all methods of therapy recorded in the treatment plan and administered to the patient

Unit 3.6: One Last Step...Before Moving on to the Next Case

Perform visual editing:

Check all dates
Check demographic information
Does the text support the primary site, laterality, histology and stage?
Well summarized documentation aids in quality assurance activities
Text documentation is required data for reporting to the Tennessee Cancer Registry.

Unit 3.7: Ambiguous Terminology

Often times, the medical record clearly indicates the patient has cancer by using specific terms that are synonymous with cancer (i.e., carcinoma, adenocarcinoma, etc.). However, a diagnosis of cancer is not always clearly stated and ambiguous terminology may be used. Ambiguous terminology may appear in any source document, such as pathology report, radiology report, or from a clinical report.
An abstract must be submitted if any ambiguous term which is considered diagnostic of cancer is used (see the following list of ambiguous terms).

Ambiguous terms that are reportable

Apparent(ly)
Appears (effective with cases diagnosed 1/1/1998 and later)
Comparable with (effective with cases diagnosed 1/1/1998 and later)
Compatible with (effective with cases diagnosed 1/1/1998 and later)
Consistent with
Favor(s)
Malignant appearing (effective with cases diagnosed 1/1/1998 and later)
Most likely
Presumed
Probable
Suspect(ed)
Suspicious (for)**
Typical (of)

Ambiguous terms that are NOT reportable
(Do not accession cases with a diagnosis based on only these terms)

Cannot be ruled out
Equivocal
Possible
Potentially malignant
Questionable
Rule(d) out
Suggests
Worrisome

**Exception: Cytology: Ambiguous terminology should not be used when evaluating cytology for reportability. Abstract the case only if a positive biopsy or a physicians's clinical impression of cancer supports the ambiguous cytology finding.

For example: A diagnosis of probable carcinoma of the colon would be considered diagnostic and the case would be reported.

A diagnosis of questionable carcinoma of the left breast would not be considered diagnostic and the case would not be reported

A possible carcinoma is not reportable.

Module 3 Review and Quiz

To accurately abstract pertinent information from a medical record, a cancer registrar should be familiar with medical terminology and diagnostic procedures.

Most medical records contain patient identification information, biographical information, medical history, and physical examination.

Reports contained within a medical record include, but are not limited to: face sheet, imaging reports, cytology reports, pathology reports, surgery reports, consult reports, discharge summary.

Each healthcare facility has its own measures for organizing a medical record. Usually, a record will be organized with the latest admission located at the front of the record.

A separate abstract is generally prepared for each unrelated malignancy.
Information may be added to the patient's medical record that was not available at initial diagnosis or at discharge.

It is usually not beneficial to abstract a case immediately upon discharge from the healthcare facility. Accepted practice allows for cases to be abstracted within six months of the date of diagnosis. This offers the opportunity for all pertinent diagnostic and treatment information to be collected in the medical record.

Quiz for Module 3

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