Feedback On Surgical Text Versus Operative Findings (Archived)
FCDS gets a lot of negative feedback on our request/requirements for Operative Findings and Surgical TX Text. Many registrars think they are the same thing – they are not. Below are the National Uniform Data Standards Data Dictionary descriptions of these required text data items. Please follow them.
If you would like to read the entire Data Dictionary description for the 2 data items, please go to the NAACCR Website, lookup Volume II Data Dictionary and then find Data Items 2560 and 2610.
While some of the ‘suggestions for text’ may overlap between the 2 fields, and they also overlap to some degree with pathology text and staging text – each is important to include in the proper section.
Furthermore, regional node dissection, sampling, or sentinel node removal is never to be implied – it is to be documented in your text in all 4 areas; staging text, pathology text, surgical treatment text for scope of regional lymph node surgery and operative text. Yes, there is repetition here – but if you follow the instructions, you don’t overlap the text much. Registrars complain that they documented xyz under operative text – usually lymph node removal – but it must also be documented under treatment text. Yes, some node dissections are implied for some primary site removal procedures such as colectomy or mastectomy. But node dissections are not always performed in these procedures. Furthermore, rectal tumor resections often do not have regional node removal. And in some instances distant nodes are removed not regional nodes. This is why it is so important to document when, where and if node dissections or other node removal procedures are performed – in the Surgical Treatment Text field.
Operative Findings should be described in the Text-DX Proc-OP field which is 4000 characters long.
Operative Findings is the “Text area for manual documentation of all surgical procedures that provide information for staging.” If information is missing form the record, state that it is missing. Many registrars simply document the name of the procedure here and copy the same information into the treatment text field RX TextSurgery. That is incorrect. There is a specific reason for documenting operative findings as sometimes a physician dictates what they ‘see’ or ‘observe’ during surgery but they may not remove one or more of the abnormalities they observe while they may still be malignant.
Suggestions for text:
Dates and descriptions of biopsies and all other surgical procedures from which staging information was derived
Number of lymph nodes removed
Size of tumor removed
Documentation of residual tumor
Evidence of invasion of surrounding areas
Reason primary site surgery could not be completed
Data Item(s) to be verified/validated using the text entered in this field
After manual entry of the text field, ensure that the text entered both agrees with the coded values and clearly justifies the selected codes in the following fields:
Surgical Text describes the actual procedure(s) performed in chronological order in RX Text-Surgery. This data item is used to document surgical treatment – it is a treatment text field, not a work-up and staging text field. It is important to know the difference and document appropriately in each field.
Surgical Treatment Text is the “Text area for information describing all surgical procedures performed as part of treatment.” This is the text field (also 4000 characters) where registrars are supposed to document treatment procedures – treatment of the primary site, removal of regional lymph nodes and/or removal of other regional or distant sites of metastasis. It is important to document the removal of lymph nodes and the resection of other regional or distant sites of tumor – but not incidental removal of organs or organs removed but included in another code such as ‘debulking’ or ‘whipple procedure’ under Surgery of Primary Site…do not double-code the surgical treatment – code it only once.
Suggestions for text:
Date of each procedure.
Type(s) of surgical procedure(s), including excisional biopsies and surgery to other and distant sites.
Lymph nodes removed.
Regional tissues removed.
Metastatic sites.
Facility where each procedure was performed.
Record positive and negative findings.
Record positive findings first.
Other treatment information, e.g., planned procedure aborted; unknown if surgery performed.
Data Item(s) to be verified/validated using the text entered in this field
After manual entry of the text field, ensure that the text entered both agrees with the coded values and clearly justifies the selected codes in the following fields:
Can’t find what you are looking for? Click on the tags below to see related articles: