California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
Enter findings from the physical examination performed by the physician.
Record the dates of the patient's physical examination
Use standard medical abbreviations when possible to save space. See Appendices M.1 and M.2 for common acceptable abbreviations.
Record any pertinent positive and negative results, including:
Location of the primary tumor and whether or not it is multifocal
Tumor Size
Extent to which the tumor has spread
Involvement of lymph nodes.