Review: Staging Sources

Here is what we have learned from Staging Sources:

  • Many sources in the health information record must be examined to determine the extent of disease and these sources are part of the diagnostic workup for the disease.
  • For most cancers, the report of the physical examination should include the location of tumor, including site and sub site, direct extension of the tumor to other organs or structures, and palpability and mobility of accessible lymph nodes.
  • X-rays, scans, and endoscopic procedures are useful for staging purposes and they can help determine the resectability of the tumor.
  • Cytologic tumor markers are tumor-specific substances in the blood serum or other tissues that can assist in determining the presence or absence of cancer; and they can help determine the initial tumor burden in both the primary site and distant sites.
  • Pathologic exams are microscopic examination of either tissue or cells, which is the most accurate method of diagnosing cancer.
  • The most important information in a pathology report includes source of the specimen, primary site, tumor size, histologic type of cancer, grade of tumor, and the extent of the disease within the organ of origin and beyond.
  • All surgical procedures should be noted in a written operative report, either as a separate entry or as part of a progress report.
  • Progress notes summarize diagnostic findings and patient status on a daily basis.