Unknown Date of Diagnosis and Treatment
The primary objective of the Florida Cancer Data System (FCDS) is to maintain a high-quality database of usable, timely, complete, and accurate data for every case of cancer identified in the state of Florida. The first course of treatment administered must be captured and reported to the state for all cancer cases.
FCDS does not accept an unknown date for the initial diagnosis. There are instructions in the FCDS Data Acquisition Manual on how to estimate the Date of Diagnosis when no information is available in the medical record. Do not use the date of admission as the date of diagnosis. You will receive an edit if the first contact date precedes the date of diagnosis by more than 30 days. It is very important to do everything possible to at least determine the year of diagnosis.
Cancer Registry software applications may allow registrars to default treatment core data items to 99 if unknown. If you do not know if treatment was recommended, performed, or refused, code to 00 (not performed) versus 99. Treatment should never be coded as 99 if you know it was performed. Treatment Recommended or Refused must be documented in the medical record, and it must be coded in the required treatment data items with supporting text documentation for all reportable cases. These instructions are for analytic or non-analytic cases.
Do not guess if treatment was performed or not. Do not presume treatment should have been recommended based on published Treatment Guidelines. Refer to the history and physical exam notes to identify if surgery or other treatment was performed for a patient with recurrence or progression of their disease. FCDS only captures first-course treatment and supporting text. If subsequent treatment(s) was administered due to a recurrence or progression, document in your text fields. Code all treatments administered, recommended, and refused, regardless of where they were done or how complete is your information.
FCDS recognizes that the medical record history and physical exams often include mention of a ‘history of cancer’ but provide little, if any, information regarding when or where the diagnosis or initial treatment occurred. This is why, for many years, FCDS has allowed registrars to enter blanks, 9s, or use the Date of Admission as a proxy for the Date of Initial Diagnosis when no information was available in the medical record. This is generally applied to non-analytic cases seen at your facility with current evidence of cancer and historical-only cases with no evidence of cancer reported to FCDS in the historical grid when new cancer has been diagnosed (multiple primaries diagnosed over the patient’s lifetime). FCDS requires every case that you abstract (analytic, non-analytic, and historical grid cases) to include, at a minimum, a valid year of diagnosis.
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