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