Alternate Name Item# Length Source of Standard Column #
2520 1000 NPCR 5565-6564

Description
Text area for manual documentation from the history and physical examination about the history of the current tumor and the clinical description of the tumor.

Rationale
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 text field must contain a description that has been entered by the abstractor independently from the code(s). If cancer abstraction software generates text automatically from codes, the text cannot be utilized to check coded values. Information documenting the disease process should be entered manually from the medical record and should not be generated electronically from coded values.

Instructions


Note: For abstracting software that allows unlimited text, NAACCR recommends that the software indicate to the abstractor the portion of the text that will be transmitted to the central registry.

Suggestions for text:


Data Item(s) to be verified/validated using the text entered in this field
After manual entry of the text field, ensure that the text entered both agrees with the coded values and clearly justifies the selected codes in the following fields:
Item name Item number
Date of 1st Contact 580
Date of Diagnosis 390
Age at Diagnosis 230
Race 1 - 5 160-164
Spanish Hispanic Origin 190
Sex 220
Primary Site 400
Laterality 410
Histologic Type ICD-O-3 522
Sequence Number--Hospital 560
Collaborative Stage variables 2800-2930
SEER Summary Stage 1977 760
SEER Summary Stage 2000 759