SEER Training Modules
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Home » Cancer Registration & Surveillance Modules » Abstracting a Cancer Case » Abstracting Diagnostic Procedures » Pathological Examinations » Cytologic Examination » Practical Examples » Example 1
- 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
Cytopathology Report Example 1
View the suggested abstraction.
Name: Kay Soper
Date: 10/06/91
Service: ________________________
Cytopathology Report
Specimen Number: 12179
- [x] Inpatient
- [ ] Clinic
Patient No.: 000048
Type and Source of Specimen: Tracheal Washings
Clinical Findings
- Ca Esophagus
- Previous Surgery
- Cytologic Exams
Do Not Write Below This Line
Screening for Malignancy
- Negative [ ]
- Atypical [ ]
- Unsatisfactory [ ]
- Suspicious [ ]
- Positive [x]
- LMP
- Parity
Comments:
The pattern suggests poorly differentiated squamous cell carcinoma
Radiation
- Hormones
- Patient's Chart
Date: 10/06/91
