Text Fields And The Cancer Registrar: Telling The Complete Story

Suzanne Neve, RHIA, CTR - Director, Cancer Registry Cancer Registry Leave a Comment

Cancer Registry Data

A cancer registry abstract provides a quick glimpse into each patient’s unique story. As part of this abstract, coded data provides specific details about the cancer, such as the disease process or specific treatment that patients undergo in each facility. However, to paint a complete picture, coded data must be supplemented by text. Cancer registrars use text fields to explain, confirm, and validate codes in the abstract. Text fields in an abstract provide information regarding the patient’s cancer defined in a readable format. Text also allows for quick access to the overall abstract without having to review the hospital’s electronic medical record or paper chart. At the state level, text assists in the determination of merged records. At the hospital level, text supports the codes and explains items that are not captured in a single code. Text is also useful for research, treatment options, audits, and overall statistics.

When using text fields in the abstract, cancer registrars should keep the following tips in mind:

  • The main purpose of text is to capture the “big picture”—not repeat details throughout each text field.
  • Text should be concise and pertinent to the cancer being reported.
  • Text should be documented in the appropriate area of the abstract. Do not repeat information from other text fields.
  • Registrars should document the facts and not make assumptions.
  • Text fields provide validation. For example, cancer registrars should indicate the results of imaging, labs, and any tests that help support the cancer being reported. This includes values coded for primary site, collaborative stage, and treatment. Also include detailed findings including positive and negative results from labs or imaging.
  • Text fields should include information from the operative report that describes the extent of the disease, sequence of surgery, and area of the body in which treatment is performed.
  • Components for text includes: Dates (Note: Indicate whether the date is an estimate), facility name, physician’s name, and location.
  • Include physician conclusions that relate to the cancer being reported.

Cancer Registry With Text Fields

In summary, text fields help registrars capture information that supports codes included in the abstract. However, registrars must remember to keep the text simple and specific. Doing so helps to tell the patient’s story most accurately and efficiently.

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