Abstracting Diagnostic Procedures
The tumor registrar must understand the events leading to the diagnosis of a malignancy. In this training module you will learn to locate and summarize statements of diagnostic procedures and findings. The real-life examples you will work with in this module were chosen to illustrate typical reports. To facilitate learning, the reports are typed instead of handwritten as in many medical records.
Sometimes the patient will have been diagnosed prior to admission to your hospital. Be sure to look for a letter or referral from an outside source.
Generally, however, the medical record begins with the patient's chief complaint (CC), medical history (Hx), or history of the present illness (HPI) plus past history (Past Hx), and review of systems (ROS). There may be separate entries for family history (Fam Hx) and/or social history (Soc Hx). Next is the physical examination (PE), usually listed by organ systems of the body.
Either directly following the history and physical examination, or at some point later, the physician will first state an impression (Imp), tentative diagnosis (Dx), or differential diagnosis (DDx). For some patients, the presence of a possible malignancy will be first detected on the initial physical examination in the hospital.
The examining physician typically will then order a series of diagnostic tests to confirm a clinical impression, distinguish one disease from among a number of possiblities, indentify more precisely the extent of the disease, and determine a patient's overall state of health. Prior to or upon admission to a hospital, patients routinely undergo examinations of their blood and urine. The findings of the examinations will be noted on one or more laboratory reports. Following this, certain diagnostic examinations may be made for the purpose of specifically determining the presence or absence of cancer. Depending upon the necessary examinations, the findings may appear on report types such as hematology, pathology, cytology, radiology, or endoscopy. There may be one or more reports of operation. All reports will be filed in the patient's medical record. You will quickly learn to recognize the relevant reports and how to abstract the diagnostic findings. For the majority of cancer patients, standard procedures are employed to establish a diagnosis. 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.
For internal tumors, where it may be difficult to obtain tissue and cells for examination, other diagnostic procedures may be used. Improved diagnostic techniques are constantly being developed while old ones are used less frequently. As a tumor registrar, you will be continually learning about new techniques.
Each diagnostic procedure will be described in detail in a separate report filed in the patient's medical record. Each report will include a description of the technique used together with a statement of the findings. These reports of diagnostic procedures will provide detailed information, which you as a tumor registrar will summarize on the abstract. In a later lesson, you will learn that the information contained in diagnostic reports is crucial to the determination of the extent of disease in addition to establishing the diagnosis of cancer.
You will find reports for conditions other than cancer in medical records. These reports should not be summarized unless specifically requested by your cancer committee. For example, you may be asked to record specific premalignant conditions, particular symptoms, or comorbid conditions.
In the following learning units, you will learn how to abstract from copies of actual reports. Note that fictitious names, dates, and identifying numbers are used in these forms.
Always record certain basic information:
- The date of the examination or procedure
- The name of the examination or procedure
- The results of the examination or procedure—any pertinent positive or negative information
- The diagnostic impression, if one is given.
As you abstract each sample report, compare your results with the suggested abstraction that can be accessed via a hyper link located at the upper right corner of the example page. In this manner you will learn how to recognize pertinent information and how to abstract it. Some reports will state the presence or absence of cancer as a "diagnosis." Other reports will contain a statement of the "impression." Do not attempt to distinguish between the two. Simply use whatever term appears on the report.