Review: Abstracting the Medical Records

Here is what we have learned from Abstracting the Medical Records:

  • A separate abstract is generally prepared for each independent cancer but specific rules may modify the general rule for selected primary sites.
  • Sequence number indicates the order in which a primary tumor is diagnosed in relation to the total number of primaries for a given patient.
  • Hospitals with cancer programs approved by the Commission on Cancer of the American College of Surgeons are required to register all carcinomas, sarcomas, melanomas, leukemias, and lymphomas, i.e. all malignancies with a behavior code of 2 or higher in the International Classification of Diseases for Oncology, Third Edition, (ICD-O-3). In situ cancers of the cervix are not reportable. Basal and squamous cell cancers of the skin are also not reportable.
  • Over time, information may be added to the patient's medical chart that was missing in the original record.
  • It is usually impractical to abstract the patient's medical record immediately upon discharge from the hospital, since there is always the inevitable delay in incorporating into the medical record the various diagnostic and treatment reports needed for abstracting.
  • If the abstracting process is initiated before the completion of the first course of therapy, it is necessary to review the patient's medical record again at a later date in order to complete the abstract.
  • A detailed list of information requirements for a tumor registry can be found in the ROADS (soon to become the "Facility Oncology Registry Data Standards" (FORDS), effective with 2003 cancer diagnoses) of the Commission on Cancer, American College of Surgeons.