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…… Support coding Support unusual site/histology combos Explain unusual abstract entries Document ambiguous terminology Document additional info or questions

And Even More Text Uses 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 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 help/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 Bilateral Bone Marrow Anterior ANT BX ABD BIL Biopsy 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 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 !