Ch. 7 General Principles of Coding and Abstracting

Abstracts

An abbreviated record that includes information on a cancer patient from diagnosis to death

Abstracts

The basis of all cancer registry functions

Abstracting time frame

Defines the interval of time between the patient’s initial contact with the institution and the completion of the abstract

Concurrent abstracting

The process of completing the abstract as information becomes available

Concurrent abstracting

Provides access to current statistics collected in the registry

Rapid Cancer Reporting System (RCRS)

Allows for the collection of minimum data elements necessary to support ongoing quality assurance programs

Rapid Cancer Reporting System (RCRS)

Allows for closer-to-real-time cancer assessments

Patient identification is found on

Admission registration form or the facility’s cover sheet/face sheet

Accession Number

A unique patient identifier. First four digits are the year patient was first seen and the last five digits are the consecutive order the case was entered into the database

Accession Number

Number does not change if reference date changes

Accession Number

Number does not change if patient has a second primary

Sequence Number

Records the sequence of malignant and non-malignant neoplasms over patients lifetime

Sequence Number

Tracks malignant and in situ primaries separately

Class of case

Indicates the type of interaction patient had with the reporting facility

Analytic case

Diagnosed and/or received first course treatment at reporting facility

Non-analytic case

Not diagnosed and did not receive first course treatment at reporting facility

Date of first contact

Date first seen at facility for diagnosis and/or treatment of cancer

Date of first contact

Cannot be prior to date of diagnosis

Date of first contact

Can be same as the date of diagnosis

Date of initial diagnosis

First date cancer was diagnosed initially or histologically confirmed

/0 Behavior

Benign

/1 Behavior

Borderline

/2 Behavior

In situ

/3 Behavior

Malignant

Reportable

Benign and borderline CNS neoplasms

Scarff Bloom Richardson Score

Breast

Gleason Grade Group

Prostate

WHO Grade

CNS

FIGO Grade

Gynecologic

4 Grade System

Colon

3 Grade System

Head and neck

First course of treatment

All treatment recorded in treatment plan and administered to patient prior to disease progression or recurrence

First course of treatment

Choice not to treat

Treatment plan

Describes therapies intended to modify, control, remove, or destroy cancer

Treatment plan

Initial treatment must begin within four months of the date of diagnosis