California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures for Hospitals
Reporting requirements for cases diagnosed and treated elsewhere are less stringent than those for other cases. The reporting hospital's medical record often does not contain the required data, or contains only secondhand data.
The CCR requires that most non-analytic cases be abstracted and submitted.
For definitions of non-analytic and analytic cases and class of case, see Section III.3.5.
For instruction on how the case should be submitted, see Section I.1.6.
Report any information included in the medical record, but it is not necessary to obtain missing information, although a hospital may choose to do so.
Text information about diagnostic procedures limited to a brief statement of the patient's history and the reason for the present admission must be included.
Enter the statement in the Physical Exam text area.
Even though information for many required data fields might not be available, all of the fields must be completed.
If necessary, enter the codes for UNKNOWN or NONE.