Alternate Name Item# Length Source of Standard Column #
2570 1000 NPCR 10565-11564

Description
Text area for manual documentation of information from cytology and histopathology reports.

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 Diagnosis 390
Primary Site 400
Laterality 410
Histologic Type ICD-O-3 522
Grade 440
Collaborative Stage variables 2800-2930
Diagnostic confirmation 490
RX Hosp--Surg Prim Site 670
RX Hosp--Scope Reg LN Sur 672
RX Hosp--Surg Oth Reg/Dis 674
RX Summ--Surg Prim Site 1290
RX Summ--Scope Reg LN Sur 1292
RX Summ--Surg Oth Reg/Dis 1294
SEER Summary Stage 2000 759
SEER Summary Stage 1977 760
Regional Nodes Positive 820
Regional Nodes Examined 830
RX Date--Surgery 1200
Reason for No Surgery 1340
RX Summ--Surg/Rad Seq 1380
RX Summ-Systemic/Sur Seq 1639