California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
Text documentation is an essential component of a complete electronic abstract and is heavily utilized for quality control and special studies. Text is needed to justify coded values and to document supplemental information not transmitted within coded values. High-quality text documentation facilitates consolidation of information from multiple reporting sources at the central registry. The length of the text fields are 1000 characters.
Report results for all analytic cases and for autopsy only (class 38) cases.
Reporting diagnostic procedures is optional for non-analytic cases; however record a brief statement of the patient's history and the reason for the present admission in the Physical Exam text area.
Text must support all coded data items and must be entered in a clear and concise manner.
Use standard medical abbreviations when possible to save space. See Appendices M.1 and M.2 for common acceptable abbreviations.
Enter text documentation in the following order, chronologically by date:
Enter date
Name of Exam
Results and other pertinent cancer related findings (negative as well as positive)
Enter text documentation that supports the following items:
Location: Refers to where the tumor is located in the primary site, such as lobe, quadrant, etc.
Tumor Size: Refers to the size of the tumor. For instructions, see Tumor Size.
Extension: The extent or growth from the primary site into other tissue or organs.
Lymph Nodes: The involvement and count of regional lymph nodes involved.
Metastasis: The involvement of distant tissue, structures, or lymph nodes.