Additional text area for staging information not already entered in other Text fields.
Text documentation is an essential component of a complete electronic report 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 reporter independently from the code(s). If 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
- Prioritize entered information in the order of the fields listed below.
- Text automatically generated from coded data is not acceptable.
- NAACCR-approved abbreviations should be utilized (see Appendix G).
- Do not repeat information from other text fields.
- Additional comments can be continued in empty text fields, including Remarks. For text documentation that is continued from one text field to another, use asterisks or other symbols to indicate the connection with preceding text.
- If information is missing from the record, state that it is missing.
- Do not include irrelevant information.
- Do not include information that the registry is not authorized to collect.
Note: For software that allows unlimited text, NAACCR recommends that the software indicate to the reporter the portion of the text that will be transmitted to the central registry.
Suggestions for text:
- Date(s) of procedure(s), including clinical procedures, that provided information for assigning stage
- Organs involved by direct extension
- Size of tumor
- Status of margins
- Number and sites of positive lymph nodes
- Site(s) of distant metastasis
- Physician's specialty and comments
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 |
RxDate Dx/Stg Proc |
1280 |
Collaborative Stage variables |
2800-2930
|
SEER Summary Stage 1977 |
760 |
SEER Summary Stage 2000 |
759 |
Regional Nodes Positive |
820 |
Regional Nodes Examined |
830 |
RX Hosp--Surg Prim Site |
670 |
RX Summ--Surg Prim Site |
1290 |
RX Hosp--Scope Reg LN Sur |
672 |
RX Summ--Scope Reg LN Sur |
1292 |
RX Hosp--Surg Oth Rg/Dis |
674 |
RX Summ--Surg Oth Reg/Dis |
1294 |
Mult Tum Rpt as One Prim |
444 |
Lateraltiy
|
410 |