Abstracting Diagnostic Procedures

A diagnostic procedure is a type of test used to help diagnose a disease or condition. (https://www.cancer.gov)

It is important for a cancer registrar to be familiar with the procedures that assist physicians in diagnosing a malignancy and where they are located in a patient’s medical record.

The information provided in this module is an example of what may be seen in a facility medical record. All medical records do not have universal preparation. A patient may have been diagnosed prior to admission. Look for office visits, consultations, or a referral letter from an outside source.

Generally, a patient’s medical record will contain documentation of the patient's

• Chief Complaint (CC)
• Medical History (Hx)
• History of the Present Illness (HPI)
• Review of Systems (ROS)
• Additional information may include family history (Fam Hx) and/or social history (Soc Hx)
• Physical Examination (PE)
• Physician first impression (Imp) and/or tentative diagnosis (Dx) or differential diagnosis (DDx)

The presence of a possible malignancy may be first detected during the initial physician clinical examination. However, diagnostic tests and procedures may be ordered to confirm a clinical impression, distinguish one disease from among several possibilities, identify more precisely the extent of the disease, and determine a patient's overall state of health. Additional reports may be found the following sections of a medical record

• Laboratory (blood and urine)
• Operative/Surgical
• Radiology
• Endoscopy
• Pathology/Cytology

A final report from each diagnostic procedure will be added to the patient’s medical record. The procedure reports contain crucial information to assist the registrar in documenting the diagnosis of cancer as well as the physician’s impression of the malignancy and extent of disease. This information will be used by the cancer registrar to complete the tumor abstract.

Information gathered from a diagnostic procedure report for a tumor abstract should include

• the date of the examination or procedure,
• the name of the examination or procedure,
• the results of the examination or procedure (positive or negative)
• the diagnostic impression, if one is given.

For the majority of cancer patients, standard procedures are employed to establish a diagnosis and there may be one or more diagnostic procedures performed. The most definitive way to prove the presence of cancer and identify its type is by the microscopic visualization of cancer cells in tissues from a suspected tumor. However, it may be difficult to obtain tissue and cells for examination and other diagnostic procedures may be used. Advances in medicine are improving diagnostic techniques making them less invasive, quicker and more accurate. It is essential for a cancer registrar to be familiar with common diagnostic tests and procedures and be attentive to new techniques.

Reports for conditions other than cancer should not be reviewed by the tumor registrar. It is important to address any requests for information other than that pertaining to the patient’s cancer diagnosis with the facility’s cancer committee. Cancer Registrars should only summarize what is needed to complete the tumor abstract.

Updated: December 28, 2023