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Abstracting the Medical Records: Unit
Review and Quiz
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Unit Review
Here is what we have learned from this unit:
- A separate abstract is generally prepared for each independent
cancer but specific rules may modify the general rule for
selected primary sites.
- Sequence number indicates the order in which a primary
tumor is diagnosed in relation to the total number of primaries
for a given patient.
- Hospitals with cancer programs approved by the Commission
on Cancer of the American College of Surgeons are required
to register all carcinomas, sarcomas, melanomas, leukemias,
and lymphomas, i.e. all malignancies with a behavior code
of 2 or higher in the International Classification of Diseases
for Oncology, Third Edition, (ICD-O-3). In situ cancers
of the cervix are not reportable. Basal and squamous cell
cancers of the skin are also not reportable, unless they
are beyond localized at the time of diagnosis.
- Over time, information may be added to the patient's medical
chart that was missing in the original record.
- It is usually impractical to abstract the patient's medical
record immediately upon discharge from the hospital, since
there is always the inevitable delay in incorporating into
the medical record the various diagnostic and treatment
reports needed for abstracting.
- If the abstracting process is initiated before the completion
of the first course of therapy, it is necessary to review
the patient's medical record again at a later date in order
to complete the abstract.
- A detailed list of information requirements for a tumor
registry can be found in the ROADS (soon to become the "Facility
Oncology Registry Data Standards" (FORDS), effective
with 2003 cancer diagnoses) of the Commission on Cancer,
American College of Surgeons.
Quiz
It's time to see how much you have learned from this unit.
A true-false quiz has been created to give you an opportunity
to reinforce what you have learned.
Since the quiz is created as an incentive for learning, rather
than an objective evaluation of learning results, the score
of the quiz will not be recorded. Instead, feedback to your
answer is provided instantaneously. So, you may select another
choice if your first choice is not the correct one.
These quiz questions are grouped into several sets of two
questions each to reduce the size of the content on each page.
When you finish the questions in one set, click the Next button
(a right-pointing arrow icon located in the Title Bar) to
proceed to the next page.
Please click here
to take the quiz.
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