Book 5 - Book 5 - Abstracting Medical Record

295 Pages·06.26 MB·English

SEER Program
Self InstructionalManual for Cancer Registrars
Abstracting a Medical Record: Patient Identification,
History and Examinations
Book Five
Second Edition
U.S. DEPARTMENT OFHEALTH AND HUMAN SERVICES
PublicHealthService
SELF-INSTRUCTIONAL MANUAL FOR CANCER REGISTRARS
Book 5 - Abstractinga Medical Record: PatientIdentification,History, andExaminations
OriginallyPreparedfortheLouisianaRegional Medical ProgramUnderthe Direction of:
C. Dennis Fink, Ph.D., Program Director, HumRRO
RobertF. Ryan, M.D., Technical Advisor, TulaneUniversity
Revised by:
SEER Program
Cancer Statistics Branch
National Cancer Institute
Editorin Chief:
Evelyn M. Shambaugh, M.A., CTR
CancerStatisticsBranch
NationalCancerInstitute
Assisted by Self-InstructionalManual Committee:
Dr. RobertF. Ryan, EmeritusProfessor of Surgery
Tulane University School of Medicine
New Orleans, Louisiana
MildredA. Weiss
Los Angeles, California
MaryA. Kruse
Bethesda, Maryland
TABLE OF CONTENTS
BOOK 5: ABSTRACTING A MEDICAL RECORD:
PATIENT IDENTIFICATION, HISTORY, AND
EXAMINATIONS
Page
Section A--Objectives and Content of Book 5 .................................. 1
Section B--The Composition and Organization of a Medical Record ................. 5
Section C--Abstracting a Medical Record: What, When, and How to Abstract ......... 13
Section D--Diagnostic Procedures: General Description .......................... 23
Section E--Clinical Examinations: Physical, Radiologic, Diagnostic Nuclear Medicine,
and Hematologic ................................................. 27
Section F--Manipulative and Operative Procedures ............................. 121
Section G--Pathological Examinations ....................................... 191
Common Abbreviations ................................................... 2.55
Common Symbols ....................................................... 267
Acronyms of Organizations Concerned with Cancer .............................. 269
The Automated Cause Coding System ........................................ 272
Acronyms for Study Groups ............................................... 273
Selected Bibliography .................................................... 275
Index ................................................................ 277
ACKNOWLEDGEMENTS
The variety of medical specialties with their ever increasing use of new techniques has made it
necessary to seek the advice of specialists in the various areas of medical diagnosis and treatment to
ensure adequate and accurate descriptions ofthese techniques for this Instructional Manual. Inevery
instance the physiciansto whom we turned have extended their assistance with the greatest goodwill.
In particular I would like to mention:
Dr. John L. Doppman
Chief, Department of Radiology
Clinical Center
National Institutes of Health
Dr. Harvey R. Gralnick
Head of Clinical Pathology
Clinical Center
National Institutes of Health
Dr. Kenneth R. Hande
Laboratory of Clinical Pharmacology
National Cancer Institute
Dr. A. Eric Jones
Nuclear Medicine
Clinical Center
National Institutes of Health
Much effort has gone into making the presentation ofthe examplesinteresting aswell asrealistic.
There is a great deal to be learned in this book, and we have tried to make it stimulating and,
perhaps, amusing with the play on names.
Evelyn M. Shambaugh
Editor in Chief
SECTION A
OBJECTIVES AND CONTENT OF BOOK 5
2
SECTION A
OBJECTIVES AND CONTENT OF BOOK 5
In this segment of instruction you willbegin to learn where to find pertinent information in the medical
record and how to record it on your cancer registry abstract. When you finish Book 5,you should have an
understanding of the usualmethods andprocedures used to diagnose cancer as well as an understandingof
precisely what should be recorded on your registry abstract.
Section B isconcerned with the composition and organization of a medical record.
Sections C. D, E, F, and G are concerned with general to specific instructions for abstracting a medical
record. Over 50 sample diagnostic, operative, and pathologic reports are included to teach you how to
abstract pertinent information from similar reports in your medical records.
4
SECTION B
THE COMPOSITION AND ORGANIZATION OF A MEDICAL RECORD
5