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When to Abstract Cases

While it may seem highly desirable to abstract the patient's medical record immediately upon discharge from the hospital, this is usually impractical. There is always the inevitable delay in incorporating into the medical record the various diagnostic and treatment reports which are needed for abstracting. Treatment may be continued over a period of weeks or months; and it may well cover more than one admission to your hospital or more than one visit to the out-patient department. Therapy, which should be incorporated into the registry record, may even be administered at another institution, on an out-patient basis, or in the physician's office. The abstract cannot be completed until the first course of therapy has been given and all the pertinent reports are filed in the medical record.

Some cancer registries may elect to initiate the abstracting process before the completion of the first course of therapy. If this is done, it then becomes necessary to review the patient's medical record again at a later date in order to complete the abstract.

For certain diagnoses, further treatment may not be anticipated; therefore, the case may be abstracted as soon as the medical record is complete. Patients who expire right away will, of course, fall into this category. You may find it necessary, however, to wait for the autopsy report to verify the diagnosis or to determine the stage of disease.