Table B

Items to Be Included in a Policy and Procedure Manual

Required Items

  • Cancer program and registry objectives
  • Cancer committee and cancer conference procedures
  • Patient care evaluation studies
  • Registry staff position descriptions
  • Case eligibility criteria
  • Reportable list
  • Casefinding sources and procedures
  • Suspense files system and process
  • Accessioning procedures
  • Filing system setup and maintenance
  • Data collection methods and data item definitions
  • Abstracting principles
  • Coding instructions and form samples and descriptions
  • Manuals, handbooks, and references to be used
  • Coding and staging systems
  • Outline of system changes including dates
  • Follow-up sample forms and letters and instructions for form completion
  • Policies for contacting patients
  • Quality control procedures
  • Reporting mechanisms
  • Guidelines for patient confidentiality and release of information
  • Data usage policies
  • Intervals and deadlines for registry operating procedures
  • Policy decisions and changes
  • Data security procedures
  • Reporting to central registries

Optional Items

  • Hospital organizational chart
  • Abbreviations list
  • Hospital bylaws
  • Budget preparation guidelines
  • Supply-ordering procedures