SEER Training Modules
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Home » Cancer Registration & Surveillance Modules » Abstracting a Cancer Case » Abstracting Diagnostic Procedures » Manipulative Procedures » Practical Examples » Example 11
- Abstracting a Cancer Case
- Abstracting the Medical Records
- Composition of a Medical Record
- Abstracting Diagnostic Procedures
- Clinical Examinations
- Manipulative Procedures
- Operative Procedures
- Pathological Examinations
- Additional Information
Manipulative Procedures Example 11
View the suggested abstraction.
Endoscopy Report
- Hospital No.: 000029
- Name: Minnie Mumm
- Service: ENT
- Sex: Female
- Age: 48
- Race: White
- Date of Operation: 6/10/91
- Clinical Diagnosis: Carcinoma of the esophagus
- Procedure: Esophagoscopy
- Anesthetic: __________
- Larynx: Normal
- Pharynx: Normal
- Trachea:
- Right Bronchus: Not visualized
- Left Bronchus: Not visualized
- Esophagus: Carcinoma of the esophagus at 18 cm. Biopsy taken.
- Diagnosis: Carcinoma of the esophagus
- Remarks:
Endoscopist A.H. Access, MD
Assistant Rich Shaw, MD
