A Well-Documented Abstract (Archived)
All central registries that report to NPCR require text documentation. Supporting text should be on all coded data items in your abstract for both analytic and non-analytic cases. If information is unavailable, state it in the abstract in the appropriate text data item. Do not simply document NA. Provide a good history of why the cancer is reported and why the patient presented to your facility. All data items must be well documented. The text helps with audits by including the primary site of origin, demographics, seer summary stage, SSDIs, and treatment administered. Your abstract text should tell a story and make sense when auditors review it. Text documentation is an essential component of a complete electronic report and is heavily utilized for quality control, visual QC, and special studies. Text is needed to justify coded values and to document supplemental information not transmitted within coded values. High-quality text documentation facilitates consolidating information from multiple reporting sources at the central registry.
Text documentation should always include the following components:
Include in the patient’s history and the reason for the visit to the facility regardless of class of case and if there is an active disease, history, or the patient is currently undergoing treatment.
The primary site should include text to support the subsite code.
Location includes the facility, physician, and other locations where the event occurred or the patient was diagnosed, including tests, studies, and treatment.
Provide dates (chronological order) and descriptions of events, including tests, studies and treatment administered and types if results were positive or negative
Treatment supporting text:
The surgery text should include all surgical procedures performed, the procedure's name, and if lymph node resection was performed to support what is coded in the scope of regional nodes.
For radiation, include dates, location, site treated, and treatment modality.
For chemo, hormones, immunotherapy includes each agent by name, not just by protocol name.
The SEER summary stage text includes the extent of disease, which may include TNM if available, and the rationale for code.
Below is a list of FCDS/NAACCR Data Items that require additional information and supporting text documentation:
2520 Text – DX Procedures – Physical Exam
2530 Text – DX Procedures – X-Ray/Scans
2540 Text – DX Procedures – Scopes
2550 Text – DX Procedures – Lab Tests
2560 Text – DX Procedures – Operative Report
2570 Text – DX Procedures – Pathology Report
2580 Text – Primary Site Title
2590 Text – Histology Title
2600 Text – Staging
2610 RX Text – Surgery
2620 RX Text – Radiation (Beam) Phase I Radiation Treatment Modality
2630 RX Text – Radiation Other
2640 RX Text – Chemo includes each agent by name, not just by protocol name
2650 RX Text – Hormone
2660 RX Text – BRM/immunotherapy
2670 RX Text – Other 2680 Text – Remarks
2690 Text – Place of Diagnosis
310 Usual Occupation
320 Usual Industry
Please refer to the FCDS Data Acquisition Manual Appendix L for a list of specific core data items that require text documentation and information on NCRA Informational Abstracts, free to download, that provide cancer site-specific information for text in abstracts at https://www.cancerregistryeducation.org/rr The Text Required section includes the set of data items where documentation must be entered to verify complete and accurate coding. Please read the Introduction to Text Documentation, which precedes this section, to become familiar with FCDS text requirements. The text requirements are monitored by FCDS QC Review and through FCDS EDITS.
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