Answer: Manipulative Procedures Example 2

08/17/91

Laryngoscopy:

Fungating mass occuping the left supraglottic area from the false cord up to the aryepiglottic fold. It does not pass the midline. Pyriform sinuses and the glottis are free of disease. The cords were moving normally. Bx taken.

Comments:

  1. The procedure "direct laryngoscopy" is sometimes abbreviated "D.L."
  2. Reporting "biopsy taken" alerts the abstractor to look for the pathology report.

The general procedures for abstracting the laryngoscopy report are:

  1. Report date and type of procedure.
  2. Record description of pertinent findings, such as location of the tumor and mobility of the cords.
  3. If biopsies were taken, locate pathology report and abstract pertinent findings.
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