Review of Staging Sources

  • Many sources in the health information record (HIR) must be examined to determine the extent of cancer and these sources are part of the diagnostic workup for the cancer.
  • For some cancers, the report of the clinical workup 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.
  • Progress notes summarize diagnostic findings and patient status daily.
  • 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 and how effective specific treatments will be.
  • All surgical procedures should be noted in a written or typed operative report, either as a separate entry or as part of a progress report.
  • Pathologic exams are microscopic examination of either tissue or cells, which is sometimes the most accurate method of diagnosing cancer and specifically staging a cancer.
  • The most important information in a pathology report includes
    • Source of the specimen
    • Primary site
    • Tumor size
    • Histologic type of cancer
    • Grade of cancer
    • Extent of the cancer within the organ of origin and beyond

Updated: March 4, 2024