MISSOURI CANCER REGISTRY
CASE COMPLETENESS/ DATA QUALITY AUDITS
Audit Data Submission Instructions
1.
PREPARE THE INITIAL DATA FILES:
a. Electronic Medical Record Disease Index (see chart and format description below).
b. Hospital Admission Type/Service code key.
c. Accession Register for the audited year.
Medical Record Disease Index
Refer to the ICD-9-CM Audit Casefinding List for case selection criteria. Refer to the following
chart to determine the months to be included in the data sampling for your hospital, based on
number of annual cases.
Annual Caseload
< 200
Jan - Dec
201 - 500
Jan
March
May
July
Sept
Nov
501-800
Jan
April
Jul
Oct
>800
Jan
May
Sept
Format of MRDI:
The medical record disease index must include cases from the following sources: inpatients,
outpatient/ambulatory surgery, hospital outpatient or clinic visits for chemotherapy, radiotherapy
or other definitive cancer treatment. Do not include patient visits for lab work or radiology.
Generate the index in an Excel file and run as a single report, rather than individual monthly
reports. Include patient’s last name, first name, date of birth, admission/discharge dates,
admission type/service codes, medical record number and at least the top five ICD-9-CM
diagnosis and procedure codes, listing them in the order in which they were originally coded.
Sort alphabetically, listing all patient encounters for the specified months under the name
(see MRDI example). Important: MRDI’s sorted other than alphabetically will not be
acceptable. If your departmental program does not have the capability to generate reports in
Excel, collaborate with your IS department to run the report in the requested format. We are
available to speak directly to the IS staff to answer any questions.
2.
PATHOLOGY
Pathology review will be performed on-site on the date specified in the initial letter.
Contact the pathology department for the requested reports and schedule a room for the auditor
for the day of the site visit. Provide pathology reports to include histology, cytology (excluding
pap smears), peripheral blood smears, bone marrow biopsies and autopsies (ALL reports for the
time period – not just those that are malignant). Refer to the table below and provide reports
for the specified months based on your hospital’s annual reportable caseload. Please note that the
months requested are alternate to the months requested for the MRDI. Provide a quiet location
with an electrical outlet. If review will be conducted electronically have the specified reports
queued and ready for the auditor.
Annual Caseload
< 200
Jan - Dec
201 - 500
Feb
April
June
Aug
Oct
Dec
501-800
Feb
May
Aug
Nov
1
>800
Feb
June
Oct
MISSOURI CANCER REGISTRY
CASE COMPLETENESS/ DATA QUALITY AUDITS
Initial Data Submission Instructions
3. DATA QUALITY
Twenty abstracts will be randomly selected from your hospital’s most recent transmission(s).
The text will be reviewed and fifteen data elements re-coded in an effort to duplicate the
abstractor’s codes. The abstractor’s codes will then be reviewed and evaluated for accuracy.
The fields to be re-coded are: diagnosis date, sequence number, primary site, laterality, histology,
behavior, grade, CS extension, CS lymph nodes, CS mets, date of first course of therapy, rx
summary surgery primary site, rx summary radiotherapy, rx summary chemotherapy, rx summary
hormone therapy.
It is not necessary to submit any records for the re-coding audit. All data will be provided and
reviewed from your hospital’s file in MCR’s master database.
4. DATA SUBMISSION:
a. The medical record disease index is to be submitted via Secure File Uploader in WebPlus
through your existing user account on the MCR website, http://mcr.umh.edu. Submit the
file in the Non-NAACCR format along with a transmittal form, completing the hospital
information section at the top and, in the Non-NAACCR section, place an ‘x’ in the box
for MRDI and record the name of the file.
b. Use the same method to submit the accession register and the admission type/service
code key, marking the appropriate boxes and recording the filenames.
c. On the Audit Checklist form mark off the initial documents, enter the corresponding
dates - your role in the initial process is finished. You will be contacted at a later date
for the resolution component of the audit.
Revised June 2009
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