Everybody’s Got A Story………..
• Text tells “the story” in
readable language that
supports the coding
• Accurate, concise
summary of the
patient’s cancer
Text Uses……
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•
Support coding
Support unusual site/histology combos
Explain unusual abstract entries
Document ambiguous terminology
Document additional info or questions
And Even More Text Uses
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Support accuracy and validity of data
Eliminate the need to pull charts again
Edit check verification
Re-coding/re-staging of historical data
Researcher/facility use
Text Uses At Central Registry
• Validate codes in the
abstract
– Sequence
– Extent
– Treatment
• Reconcile codes and
consolidate abstracts
from different facilities
• QC audits
Critical Data Items
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Age ** DOB
Sex
Race
Sequence number
Stage
Date of diagnosis
Laterality
•
•
•
•
•
Primary site
Histology
Behavior
Grade
Dates and types of all
treatments
Picturing this???
It’s not the amount of text… it’s how
you use it!
• Be concise- quality is
more important
than quantity
• Only document
what’s relevant to
the site/disease
• Use abbreviations
Abbreviations!!! Use ‘em…..
Use accepted abbreviations from the Abstractor’s
Manual available at
http://www.kcr.uky.edu/manuals/cpdmshelp/cpdms.htm
Appendix I
(Common Acceptable Abbreviations)
….But Use Caution!
• Make sure your
abbreviations aren’t
confusing
• Spell out, at least once,
any abbreviation that
might not be easily
recognized
• Use abbreviations in
context
In addition to abbreviations, using
symbols is also acceptable.
<, >, =, &
+ (positive), x (times)
2/7 (two of seven)
You can omit vowels or use
apostrophes to shorten words.
Glsn (Gleason), Blm-Rch
(Bloom-Richardson)
Rec’d, dx’d
Match the abbreviations!
Abdomen
ANT
Bilateral
BX
Biopsy
ABD
Bone Marrow
BIL
Anterior
BM
Health and Physical: Demographics
• Name(s)
• Social Security
Number
• Age….and DOB added
is nice
• Sex
• Race
• Ethnicity
• Birth place
History and Physical
• Any previous cancer dx? When? Where?
• Describe the symptoms leading to the current
admission (inpt or outpt) for dx and/or tx
• Remember to focus text on the cancer being
dx’d and/or tx’d at this time
History and Physical
• Was this cancer dx’d at your facility or a
different one?
– Where? (give the facility, office, etc.)
– Give the date, site and histology
• Has this cancer been previously treated?
– Procedures, treatment, drugs, dose
– Dates
– Location
• End with your initials and the date
Example
• W/F, non-Hispanic with pelvic pain growing
worse over the past 3 months. US at outside
facility showed solid 10 cm mass rt ovary.
Referred here for eval and tx. KDK 7/12/12
Imaging
• Include the date, scan type, and facility where
performed
• Include only info relevant to the primary site
– Any positive findings
– Any negative findings that define stage
• Support your codes for CS Tumor Size, CS
Extension, CS Lymph Nodes, CS Mets at Dx
• End with your initials and the date
Scopes
• Include the date, scope type, facility where
performed, and the relevant findings
• End with your initials and the date
Lab Work
• Document tumor markers and site specific
factors
• Document factors affecting prognosis or
staging
Lab Work
Include :
• Date of Test
• Facility Where
Performed
• Result (value)
• Normal Range
• Your Initials with Date
11/21/12 UK: CEA
12.3 (nl < 5.0 ng/ml)
KDK 4/13/13
Operative Findings
• Include the date, name of procedure, facility
where performed, relevant findings and may
also include
– Organs removed
– Any differences between intended procedure and
actual procedure
– Important site, size or staging info
• End with your initials and the date
Pathology
• Include the date, tissue taken, report number,
facility where performed, site tissue was taken
from, final diagnosis
• Include results regarding size, location,
histology, grade, extension, LNs
• Comments and addenda are important and
should also be included
• End with your initials and the date
Site
• Document the primary site (topography) as
described in the medical record
• Document laterality
• End with your initials and the date
Histology
• Document the date and source of tissue
• Support your code for the primary tumor type
– Include the final dx from cyto, path or clinical
assessment
• Document behavior and grade
• End with your initials and the date
Staging
• Document TNM staging and who staged the
patient
• Document whether there is clinical and/or
pathologic staging
• For Collaborative Stage, show the original
measurements and include the sources
• Include any info for Site Specific Factors if not
covered elsewhere
• End with your initials and the date
Other
• Include info for :
– Date of Dx, if not covered in earlier text
– Class of case
– Therapy planned and/or received including type,
volume, modality
– Following physicians
– Follow-up info sources
• Follow-up info will typically be added here each
year…along with your initials and the date
Reabstracting Audits!
Are often performed
using text
information
only….data not
documented will be
counted as errors.
Conflicting Info
• What if you follow the
rules and your staging
doesn’t match the
physician staging?
• Code according to the
rules and document
how you arrived at your
code (i.e. support your
coding with text)
Follow-Up
• Systematic process of obtaining accurate
information, at least annually, on the patient’s
health, vital status, and progression of disease
Follow-Up
• Can assist in the early identification of
recurrence
• Assists physician’s in getting former cancer
patients to return for treatment or checkups
• Encourages periodic examination of cancer
patients since they are prone to develop other
cancers
• One very, very important word…..survival
Follow-Up Rules
Follow-up info necessary for analytic cases only,
with the following exceptions
Patients who are currently residing in
foreign countries e
Patients whose only malignancy is
carcinoma in situ of the cervix
The College (aka ACoS)
• Follow-up is considered delinquent by ACoS if
info is not obtained and documented within 15
months of the patient’s previous date of last
contact
• For an approved program, a follow-up rate of
90% of a hospital’s analytic cases in the past 5
years is needed to be in compliance
Follow-Up with KCR
• Current follow-up must
be reported to KCR for
every case dx’d since
1995 that is class 00-22
• Considered current if
Date of Last Contact is
within 15 months of
current date
• CPDMS.net can create a
report for patients
needing updated
follow-up
Word To The Wise…..
• Always maintain
the highest
follow-up rate
possible!
• Falling behind is
trouble that’s
easy to get
into….and hard to
get out of
What To Collect
• Date of Last Contact
• Survival status
• Current address
• Disease status
• Recurrence info
• Additional treatment
received
• Cause of death, if
deceased
• Method of obtaining
follow-up
A Few Words About Treatment
• Obtaining complete first course treatment info
is extremely important
• Follow your registry rules, but a brief
documentation (date, type, drug(s), start &
stop dates) in the treatment notes section is
ideal
Questions?
• Thanks to Kim
Kimbler for her
creative efforts in
developing this power
point presentation !