Abstracting Manual

							ABSTRACTING
  MANUAL
    For
 PC DaSHW
    July, 2007
These instructions refer to each field within PC DaSH. They are written in
sequential order, starting with the first screen you will see.

Note: ACoS specific items are grayed out and bypassed if abstracting at a Non-
ACoS facility. Please refer to Special Fields and Buttons section of the PCDaSH
for Windows User Manual.

Within these instructions, you will find reference to certain pages within the
FORDS manual.

Let’s begin:

SIGNING IN:

ABSTRACTOR NUMBER: Enter the abstractor number assigned to you by
NMTR, with two leading zeros. (example 00011)
PASSWORD: Use your personal password that you have chosen for PC
DaSHW.
The blue Upload screen will appear. This field will let you know how many cases
are ready to be transmitted.

HOSPITAL NUMBER: enter the code of the facility where you are abstracting.

An “FYI” screen will come up, explaining how to start using PC DaSHW. Hit
CLOSE to continue.

To initiate an abstract, go to FILE, then to PATIENT SEARCH. The
INSERT/UPDATE/INQUIRY screen will appear. To check for your cases, select
the files you wish to search, then the type of search, whether it be by name, date
of birth, etc. For abstracting purposes, most of the time the Select Files to be
Searched should be ALL and the Enter Search Type should be 1. NAME. Hit
enter after the Search Type and type in the name, DOB, etc., of whatever it is
you are using for the source of the search. Then hit SEARCH. (Right side of
screen)

If the case is within the MASTER file, the column on the left-hand side named
TYPE will have an M. If this is the patient’s second (or more) primary, click
VIEW RECORD button on the bottom of the screen, left-hand side. This will
open the Master record summary page. Click EDIT RECORD to bring up the
master record. It will look just like the abstracts you’ve been doing. Go to the
Tumor Level and review the demographic information to see if it needs updating.
Then ADD a tumor. Make sure you enter the patient’s casefinding number,
so the case will be deleted from casefinding.




                                         2
If this is the patient’s first primary and is listed in Casefinding, the case will have
a C as the type, on the left side of the name. You can initiate a new abstract
from the casefinding. This will autocode any fields that were entered into the
casefinding.
Highlight the case by clicking on the bar with the C and hit “View Record” on the
bottom left-hand side of the screen. It will show you what is listed in the
casefinding Master.
 After determining that this is the case you want to abstract, hit “Abstract” button,
found on the bottom right-hand side of the screen.

If you leave the abstract and want to re-enter your abstract, complete the patient
search, the same way as listed above. Next to the patient’s name, you will find an
A. This means your abstract is still within the suspense file and has not been
transferred to the master file yet. Highlight the “A” enter (will appear dark blue)
then hit the View Record at the bottom of the left-hand side of the screen. A
Facility Data screen will appear. To enter your abstract, hit the Edit Record
button on the bottom of the screen on the right-hand side. You are now in your
abstract.
Once you initiate the new abstract, the following fields are ready for your entry.
NOTE: IF THE CASE IS AUTOCODED FROM CASEFINDING, PLEASE BE SURE TO CHECK
ALL THE DEMOGRAPHIC FIELDS, ESPECIALLY DATE OF BIRTH AND SOCIAL SECURITY
NUMBERS. IF INCORRECT, PLEASE CHANGE TO WHAT WE HAVE IN E-WEB AND
PORTAL.

PATIENT’S LAST NAME: For the purpose of matching for follow-up and
editing, specific rules must be followed when entering the patient’s last name.
Do not use hyphens. Do not record Jr’s, Sr’s, MD, etc. in this field.. For A.K.A.
do not add abbreviated names (e.g. Jim for James). See AKA field.


FIRST NAME: Record the patient’s first name, Only alphabetic characters can
be used.
MIDDLE INITIAL: The face sheet in the medical records does not always give
the patient’s middle initial, but many times this can be found on a signed consent
form in the back of the chart.
SUFFIX: If the patient is known as senior (SR) or junior (JR) enter the suffix
here.
CONTACT TYPE AND NAME: In e-Web, a contact name is generally listed.
Enter the contact person’s name. This may be used for follow-up as well as a
contact person for special studies. Only alphabetic characters can be used.




                                           3
PATIENT CONTACT CODES:
      00     none
      01     Spouse
      02     Parent
      03     Sibling
      04     Son or Daughter
      05     Guardian
      06     Neighbor or Friend
      07     Doctor or other medical person
      99     Other

CURRENT ADDRESS:
This reflects the patient’s residing address at the time of the patient’s last
contact. This may be updated at any time. Due to space issues some towns/
cities must be abbreviated, they are as follows;
Town/City                                  Abbreviation
ANTELOPE WELLS                             ANTELOPE WLS
BLACK RIVER VILLAGE                        BLK RIVER VLG
CHAPARRAL PARK                             CHAPARRAL PK
CLINES CORNERS                             CLINES CORS
CONTINENTAL DIVIDE                         CONTINENTAL DIV
DZILTH NA DITH HLE                         DZILTH NA O
ELEPHANT BUTTE                             ELEPHNT BUTTE
GILA HOT SPRINGS                           GILA HOT SPRGS
GONZALES RANCH                             GONZALES RNCH
HIGH ROLLS MOUNTAIN PARK                   HI RLS MTN PK
KIRTLAND AIR FORCE BASE                    KAFB
LOWER COLONIAS                             LWR COLONIAS
MEXICAN SPRINGS                            MEXICAN SPRGS
NAVAJO WINGATE VILLAGE                     NAV WINGTE VLG
OLD HORSE SPRING                           OLD HORSE SPG
POJOAQUE VALLEY                            POJOAQUE VLY
PUERTO DE LUNA                             PUERTO DE LNA
RADIUM SPRINGS                             RADIUM SPGS
RANCHOS DE TAOS                            RNCHS DE TAOS
SAN JUAN PUEBLO                            SAN JUAN PBLO
SANTO DOMINGO PUEBLO                       SN DMNGO PBLO
SAN ILDEFONSO PUEBLO                       SN ILDFNS PBL
TRUTH OR CONSEQUENCES                      T OR C
TAOS SKI VALLEY                            TAOS SKI VLY
TIERRA AMARILLA                            TRA AMARILLA
UNIVERSTIY PARK                            UNIVERSITY PK
UPPER COLONIAS                             UPR COLONIAS
WEST LAS VEGAS                             W LAS VEGAS
WHITE SANDS MISSLE RANGE                   WHT SANDS MR


                                        4
Supplemental patient address: This address field should be used if the patient
lives in a nursing home or an apartment complex, where the name of the
establishment is part of the address. Examples would be “Shady View
Retirement Community” or “Route 66 Motel” The name of the establishment
would be entered in this field. If the patient just has a street address, LEAVE
THIS FIELD BLANK. Do not enter same.

TELEPHONE NUMBER: Enter the patient’s current telephone number in this
field. If the telephone number is unknown, code to 000-0000.

SOCIAL SECURITY NUMBER (SSN): Enter the patient’s social security number
in this field. If the social security number is not given, but a Xerox copy of the
patient’s Medicare card is in the chart, note the last digit of the social security
card number. This should be a letter. If the last digit is an A, the social security
number on the patient’s Medicare card represents the patient’s social security
number. Enter that number in this field. If the SSN is unknown, code to
999999999.

DATE OF BIRTH: code the patient’s birth date. If DOB is unknown but age is
given, estimate the year and code month and date to 9999. (Page 57 in the
FORDS Manual, 2007)

PLACE OF BIRTH: If stated within the chart, code this field. If not stated, code
to 999. For a list of the codes, see Appendix B in the SEER Program Coding
Manual, 2004. These are not listed in FORDS)

RACE: code the race based on documentation within the chart. Race may be
stated on the face sheet or within physician and nurse’s notes. If the patient is a
Native American and you know the patient’s tribe, enter the tribal name in the
Attention: Editing narrative.
.At NMTR, the code 00 has been added to the NAACCR race code list. 00 is
used for coding patients who are reported to be white, but are not of Hispanic
descent. The code 01, normally used by NAACCR facilities for white is reserved
for patients of Hispanic descent.

* (See page 60-64 in the FORDS Manual, 2007, for additional guidelines on
coding race) Enter Race in the first field, then enter through the second field.
If race is unknown and there is no information in chart code race to white (NMTR
rule). If race is not listed in chart and patient has a Spanish surname code race
to 01.




                                         5
SPANISH SURNAME: Spanish surname is based on the patient’s birthplace.
For this SEER registry, if the patient has been noted to be Hispanic (you have
coded race as 01), the following rules are used to determine the correct code:

   0         The patient’s race was coded to other than a 01.
   1         The patient must have a birthplace of Mexico. If the chart states the
             patient is “Mexican”, but the birthplace is New Mexico or Texas, this
             code cannot be used. This code must have the birthplace coded to
             Mexico.
   2         The patient must have a birthplace of Puerto Rico.
   3         The patient must have a birthplace of Cuba.
   4         The patient must have a birthplace of South or Central America
             (except Brazil – code race to 0 for Brazil)
   5         For this SEER registry, we have reserved this code to represent our
             Hispanic patients who were Born in New Mexico.
   6         If we have coded the patient to Hispanic, but we do not know where
             the patient was born or if the patient was born in another state other
             than New Mexico, use this code. Unknown birthplace or another
             state.
   7.    If the patient is a married female with a Hispanic last name and the chart
        does not indicate whether the patient is Hispanic or Anglo, use this code.
   8.   The patient must have a birthplace of the Dominican Republic.
   9.   Unknown.

   SEX: code gender. 1. Male 2. Female 3. Hermaphrodite (born with both
   male and female organs) 4. Transsexual (surgical alterations) 9. Unknown

Hit Save at this time


DATE LAST SEEN: Enter the most recent date found within the chart. If the
patient was re-admitted or came in for additional tests following the initial
admission, code the most recent day he was seen.



CONTACT ALLOWED: Code 1= contact permitted. Code 2 contact not
permitted. If there is indication in the medical record of the patient being autistic,
alzheimers, patient is not aware of their diagnosis, etc. code to 2- contact not
permitted.

VITAL STATUS: Indicates whether the patient was alive or dead on the date of
last information. 1 is Alive 4 is dead

If coding patient to Dead and death information is unknown; code DC number to
999999999 , DC status to 9, Autopsy indicator to 9 and Cause of Death to 7777.



                                           6
FOLLOW-UP PHYS: Enter the code of the physician who will be following the
patient for this cancer. If unknown enter 9999.

FOLLOW-UP FACILITY: Enter the code of the facility where the patient will be
followed.

*FOLLOW-UP SOURCE: Records the source from which the latest follow-up
information was obtained. See page 203 in the FORDS 2007 manual for these
codes.

*NEXT FOLLOW-UP SOURCE or METHOD: This field is used to identify the
method planned for the next follow-up. Most of the time, this field will be coded to
0, chart acquisition. If the patient has moved to a foreign country, such as
Mexico, code to 8. If the patient is dead, code to 9 – Not Followed. (See Page
204 in the FORDS 2007 Manual for all codes)

FOLLOWING REGISTRY: Enter the code of the facility where the patient will be
followed.


Then Hit Save and Edit Demographics (your PC DaSH Edit Report will
appear behind the current screen. With your mouse, move the screens and
hit the mouse key to review it. It will tell you what errors you have made or
will tell you “Great Job”. To continue, close the TURQUOISE door on the
bottom right hand side of that screen or hit the X box in the upper right
hand corner. This screen needs to be closed for each edit review. Don’t
forget to do that.

AKA TYPE AND NAME: This field can be left BLANK if no AKA is available.
 If the patient does go by another name, that is not a general nickname, such as
Bill for William, record the name in this field, indicating whether the other name is
the first or the last name. Examples would be:

James William Smith         AKA: JW Smith (first name is the AKA)
Margarita Maria Baca        AKA: Maria Baca (first name is the AKA)
Mary Ann Smith-Taylor       AKA: Mary Taylor (last name is the AKA)



GO TO THE NEXT TAB, WHICH IS TUMOR LEVEL

This level will show the Narrative Tabs on the bottom of the screen. Before
starting your coding, enter the narrative. This will allow you to use your narrative
to assist in your coding.




                                          7
                      BASIC RULES FOR NARRATIVE
   The Copy and Paste feature can be used for narrative when an electronic medical record is
   available
To copy and paste: hit <ctrl><c> to copy, to paste – click on where you
want to paste it and hit ,<ctrl><v>.



   This is the abstract portion or the summary where text is documented to
   support the all of the coding . Basic rules are used concerning what should
   (and should not) be entered onto this page. If reports are not available for
   one of the categories you must document “None” in order to clear the edits.
   These rules are as follows:

CLINICAL FINDINGS:

      The date of admission (this may or may not be the date where you obtain
       this information. Clinical findings should be a combination of admission
       and consults prior to the patient’s treatment.)
      Start this narrative using the age, marital status, race and sex. Example:
       65 year old married white female would be written as 65 y/o MWF. Try to
       keep this order, so everyone will know what the meaning represents.
       Single should be represented by an S. Separated should be represented
       by SEP.
      Physical Exam, to include palpable mass, lymph nodes or visible signs of
       the tumor.
      The physician’s impression or assessment.

X-RAY:

      Record all CT, PET, and other nuclear medicine and radiologic findings,
       starting with the date, the procedure and pertinent findings.
      Record any imaging reports that will substantiate the metastatic status of
       the tumor. Such imaging reports might be an MRI of the brain, a bone
       scan or a whole body CT scan. (Thorax/abd/pelvis)



SCOPES:

      Record any scopes, such as colonoscopy, endoscopy, etc., starting with
       the date, type of scope and the description of the tumor seen on the
       scope.




                                              8
LAB TESTS:

      The lab findings needed to substantiate any SSF’s can either be stated
       here or in the pathology narrative.

OP: (surgical findings)

      Record any biopsies done, including FNA and surgical procedures.
      Record the date of the procedure, the name of the procedure followed by
       the description of the tumor as indicated within the surgery report. If the
       operative report is technique only- document “Technique only”.

PATHOLOGY NARRATIVE:

      Record all pathology report findings that will substantiate your coding.
      Record the date of the pathology report.
      Record the Final Diagnosis.
      If the tumor size is not within the final diagnosis, find the tumor size within
       the gross and record.
      If a microscopic report is given, scan through it to obtain any additional
       information concerning the extent of disease that may substantiate your
       coding.

STAGING
     At this time, we have no use for this narrative field, but something must be
     entered, so just put none.
REMARKS
    A good place to put a summary of the entire cancer case and/or the
    discharge summary. This field can also be used to document additional
    rationale for coding EOD, Site, Histology, etc., if necessary.

After completing your narrative, the Tumor Level can be filled out. There
are Six tabs on the top for the Tumor Level. Following are the instructions
for each one.




                                          9
TUMOR SEQUENCE: This represents the number of cancer primaries for this
patient. If the patient has more than one primary, you will need to determine the
proper sequence of the primaries, starting with the 1st primary found and ending
with the most current primary as the highest number.

00 = one primary
01 = 1st of more than one primary
02 – 2nd of two or more primaries

Benign tumors are also collected, but these are not included within the
sequencing of cancer primaries. These are sequenced as follows:

   60 = one benign primary
   61 = 1st of more than one benign primary
   62 = 2nd of more than one benign primary


If the patient has a record of cancer(s) prior to this patient’s admission, but the
prior primaries were not abstracted at this facility, these cases must still be
sequenced. Refer to page 69 of the SEER code manual or page 34 of the
FORDS manual.

DATE OF DIAGNOSIS: This is the date that a recognized medical practitioner
first called the patient’s condition a cancer. This date could come from a physical
exam, imaging, a biopsy, a lab report, surgical findings or pathologic exam of a
resected tumor.

DIAGNOSING FACILITY: Enter the facility code where the patient was
diagnosed. If the patient was diagnosed at a facility with an umbrella code like
0080 (Presbyterian Hospital) code to the specific facility code such as 0021,
0022, etc. If the patient was diagnosed in a private physician office enter the
physician code. If the facility or physician code is unknown- type in the name and
the program will search for the code. Do not code a radiologist as the diagnosing
physician- code the physician who ordered the biopsy. If the diagnosing facility
or physician is unknown enter 9999.


If the Case was diagnosed in 2007 or after, the following fields will appear:

*Ambiguous Terminology: Identifies whether the case was diagnosed initially
based on ambiguous terms. See Pages 99A –99B in the FORDS 2007 Manual
for explanation or refer to pages 335-337 of the Multiple Primary and Histology
Coding Rules.




                                         10
*Date of Conclusive Dx: This allows allows for analysis of the time interval
between the initial diagnosis, based on ambiguous terminology and a firm
confirmation of cancer. See Pages 99C-99D in the FORDS 2007 Manual for
explanation. Refer to page 338 of the Multiple Primary and Histology Coding
Rules.

*Multiple Tumors Reported as One Primary: If patient has more than one
tumor within a primary site, but we coded this to one primary, we can record the
findings here. See page 99G in the FORDS 2007 Manual for explanation. Refer
to page 342-343 of the Multiple Primary and Histology Coding Rules.

*Multiplicity Counter: If we coded the above field as more than one primary, we
put how many tumors were found in this field. See pages 99H-99I in the FORDS
2007 Manual for explanation. Refer to pages 339-340 of the Multiple Primary and
Histology Coding Rules.

*Date of Multiple Tumors: This date represents the day they realized the
patient had more than one tumor within the primary site. It may or may not be the
diagnosing date. See pages 99E-99F in the FORDS 2007 Manual for
explanation. Refer to page 341 of the Multiple Primary and Histology Coding
Rules.

*Type of Multiple Tumors Reported as One Primary: This data item is used to
identify the type of multiple tumors abstracted as a single primary. Refer to page
342-343 of the Multiple Primary and Histology Coding Rules.

ADDRESS AT DIAGNOSIS: This field represents the patient’s residence at the
time of diagnosis. If the patient was diagnosed prior to the admission to your
facility and the patient’s address at the time of diagnosis is unknown, code the
address in the following manner:

STREET (PLACE A DASH) -
CITY: UNKNOWN
STATE: NM
ZIP: 87500

The dash ( - ) will represent an unknown street address. If the city is known,
enter the city. An example would be if the notes state he was diagnosed in San
Francisco, then enter San Francisco in the City. For the State, it if is unknown,
default to NM unless you know the patient was diagnosed out of state but don’t
know where then enter XX.. If the state is known, enter the state. The general
delivery zip code for the state’s capital is entered in the zip code field, if the
address is unknown. For NM, this zip code is 87500. Code unknown zip code to
99999 for cases diagnosed out of state.




                                        11
In order to utilize the computerized census tract, addresses must be entered in a
specific format. Again, no punctuations can be made, such as commas or
hyphens. Below are listed some of the rules for coding the address at diagnosis.
If the abstractors abide by these rules, editing’s time on each abstract will be
reduced. Please try and abide by these rules.

Abbreviating the “type of” street.

Road: RD      Street: ST Avenue: AV Drive: DR Trail: TR                 Circle: CR
Court: CT     Lane: LN Loop: LP Way: WY Freeway: FW                     Place: PL

Highway: HY      Boulevard: BD       Parkway: PW       Park: PK

Abbreviating quadrants

If the street address has a quadrant, such as “N Central Blvd” the quadrant “N”
should be placed at the end of the address.

Example: S First Street would be entered as 1st ST S.

The Quadrant abbreviations are as follows:

North: N    South: S     East: E     West: W

Northeast: NE     Southeast: SE      Northwest: NW       Southwest: SW

Apartments and Space
If the patient lives in an apartment or in a mobile home park, where space
numbers are assigned, the apartment or space number must go behind the
address, after the quadrant letter, if one exists. Do not use the # sign for the
apartment or space.

Some examples of correct address entry:

9999 A-234 Montgomery Blvd NE would be entered as:
9999 Montgomery BD NE A234

1234 Apt. C. Montgomery Blvd NE would be entered as:
1234 Montgomery BD NE Apt C

444-1/2 NW Nineteenth Street would be entered as:
444 19th ST NW ½ (because the ½ represents part of that address, such as a
duplex and the numbered street cannot be written out)

23000 Highway 71 South would be entered as:
23000 HY 71 S



                                         12
Albuquerque abbreviations

If the patient’s residence is Albuquerque, you can type in ALB OR ALBUQ and hit
enter and Albuquerque will automatically be spelled out. Only these two
abbreviations will work. Albuquerque must be spelled out in full in order to clear
the edits An incorrect abbreviation will not spell out Albuquerque.

City:
Refer to the town/city abbreviations found under Current Address field.

If the address at time of diagnosis is the same as the current address enter the
word SAME in the street field and hit enter. The address will be auto coded with
current address.

County at Dx is an autocode field.

Supplemental Address at Dx: This address field should be used if the patient
lives in a nursing home or an apartment complex, where the name of the
establishment is part of the address. Examples would be “Shady View
Retirement Community” or “Route 66 Motel” The name of the establishment
would be entered in this field. If the patient just has a street address, LEAVE
THIS FIELD BLANK. Do not enter same.

Place of Dx: This is not a SEER or a CoC field. We can leave this blank.

MARITAL STATUS: Code the marital status at the time of diagnosis. This
field will never change. If you do not know what the status was at the time of
diagnosis, code to unknown.

1     Single
2     Married
3     Separated
4     Divorced
5     Widowed
9     Unknown

Age @ Dx and Survival in Months are autocodes.

Tribe Code: Document tribe code in the Attention Editing field. If unknown,
document “Tribe unknown”.




                                       13
CLASS OF CASE: This field is required by the Commission on Cancer
Approved Program Facilities.
  0      This represents a case that was diagnosed at your facility. The patient
         did not receive any planned first course of treatment at your facility.
  1      This represents a case that was diagnosed at your facility and has
         received all or part of their planned first course of treatment at your
         facility.
  2      This represents a case that was diagnosed at another facility and
         came to your facility for all or part of their planned first course of
         treatment.
  3      This represents a case that was diagnosed and their entire planned
         first course of treatment was done at another facility.
  4      This represents a case that was diagnosed and/or treated at this
         facility prior to the CoC Approved Program’s reference date. Pres’s
         reference date is 01/01/1967.
  5      This represents a case that was diagnosed solely on an autopsy.
  6      This represents a case that was diagnosed and treated in a staff
         physician’s office.
  7      This represents a case abstracted from a pathology report only.
  8      This represents a case abstracted from a death certificate only.
  9       Use this code if the case does not fit any of the above.

STATUS OF TUMOR: This field reflects the patient’s cancer status on the Date
of Last Activity Information. This field should be updated, when the registrar
updates the patient’s follow-up date. While abstracting the case, this code will
reflect the Date of Last Activity. If updating a date of last activity within the
PC DaSH database and the tumor status is unknown, do NOT change this
field. This only changes when recurrence or freedom from disease is
stated by a medical professional.

The codes are 1 for no evidence, 2 for evidence and 9 for unknown. The rules for
coding for this field are as follows:

      If the patient has undergone definitive treatment of the primary site, the
       physician will generally note that the patient is disease free. (code to 1)
       Radiation therapy to the prostate is considered definitive therapy and it is
       assumed that if he has completed his treatment, he is now disease free.
      If the patient has had palliative care only, such as XRT or chemotherapy
       for pain control, but no treatment to the primary site, he is considered to
       have evidence of disease (code 2).
      The patient has had a recurrence, but this recurrence was removed via
       surgery, or XRT/chemotherapy was administered and the latest CT scan
       now shows no evidence of disease at the date of last activity, the patient is
       considered disease free. (code 1)
      The patient is admitted with a recurrence, but no treatment is given,
       consider the patient as positive for evidence of disease. (code 2)


                                        14
If it is unknown whether the patient ever became cancer-free or ever had a
recurrence, code to unknown. (code 9)

Census Tract – Geocode and Certainty are autocodes.

SAVE and Edit Tumor Diag Info

Go to TUMOR IDENTIFICATION (next tab on the top)

(Cases diagnosed 2007 forward, refer to the Multiple Primary and Histology
Coding Rules)

PRIMARY SITE: Using the guidelines given within the FORDS 2007 Manual, or
page 69 of the SEER Coding and Staging Manual 2007. Enter the ICD-0-3 code
for the correct primary site.

HISTOLOGY: Using the ICD-0-3 book and the guidelines given in the FORDS
Manual, or pages 78-81 of the SEER Coding and Staging Manual 2007. Enter
the ICD-0-3 histology code.

Site Group: Autocode

*GRADE: Using the guidelines given within the FORDS Manual, pages 96-97,
enter the correct grade code. Do not code the grade from a metastatic site.
Do not code grades given within the lymphoma histology, such as 9665/3
Nodular sclerosis Hodgkin Lymphoma grade 1. Do not code WHO grades
for CNS.
LATERALITY: If the primary site you have chosen has a required laterality
code, the cursor will stop at this field. Code the laterality code using the
guidelines found within the SEER Coding and Staging Manual 2007 pages 73-
75.

*DIAGNOSTIC CONFIRMATION: Code the method of diagnosis using the
guidelines on page 99 in the FORDS 2007 Manual. Refer to he SEER Coding
and Staging Manual 2007 page 76. Positive histology takes precedence over all
the others.
REPORTING SOURCE:
1= Hospital/ Clinic
2= Radiation Treatment Center or Medical Oncology Center
3= Laboratory
4= Physician office (path only cases)
5= Nursing Home/ Hospice
6= Autopsy
7= Death Certificate
8= Other hospital outpatient units/ surgery centers


                                       15
CASEFINDING SOURCE: The two codes we will mostly use in this field will be
20 – for e-Path and 22 for disease index. (note: on the casefinding list, the code
for disease index is 02) See drop down menu.
Depending on the year of diagnosis, either EOD or Collaborative Staging
will appear at this time.

COLLABORATIVE STAGING: Using the Appendix –C of the SEER Program
Coding and Staging Manual, 2004, or the Collaborative Staging Manual, code
the collaborative staging fields for the primary site as indicated on this page.
Hit the Calculate button after finishing Collaborative Staging

The Derived TNM will show up in the next boxes, as well as the Summary Stage.
Check to make sure that this is the correct TNM you wanted. If it is not, go
back and correct the Collaborative Staging, then re-calculate the Derived
TNM.

TNM Edition Number: If the case does not have a TNM scheme, code to 88.
Otherwise, use the edition that corresponds with the date of diagnosis.

Commission on Cancer Coding System: The edition number should
correspond with the date of diagnosis.

TNM Clinical and Pathological: These fields are reserved for the physician’s
staging from the TNM forms given to them to complete. The clinical and
pathologic staging will be entered into the COMMENTS field within the
casefinding. Watch for the staging on your casefinding list and enter the staging
into these fields. Code exactly as indicated on the casefinding list. If it states the
physician left the field blank, then leave the field blank in PC DaSHW.
 See Page 123 in the FORDS 2007 Manual for the Staged by codes.



DISTANT METS: Code distant mets found at the time of diagnosis in this field.

Edit Tumor ID and go to Comorbid Conditions

*Co-morbidities and Complications: The comorbid conditions and
complications can be found on the HDM systems or, if the patient had a lengthy
admission, they can be found on the face sheet within Chart One or e-Web. Do
not code all of the codes. Use the guidelines given on pages 69 in the FORDS
manual for what NOT to code. If the patient does not have any co-morbidities
listed, fill the first box with zeros.

Next tab – Other Sites



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OTHER PRIMARIES:
If you have determined that the patient has had other cancer primaries and you
have listed the sequence number accordingly, the other sites must be entered in
this field as well as the date of diagnosis. The date of dx may be estimated.

Edit other Sites (don’t forget to “close” the turquoise door)

Overrides and Hospital Specific are N/A at this time


Go to Admissions tab in the middle of the page

CASEFINDING #: When the case was entered into casefinding, the computer
assigned a casefinding number to the case. By entering this casefinding number
into this field, this casefinding number will be automatically deleted from the
facility’s casefinding list. If it does not show up within the casefinding box and you
have a number, enter it at this time.

FACILITY CODE: Should be the specific facility code rather than the combined
facility code. Example; 0021 or 0022 rather than 0080.

ACCESSION NUMBER: The accession number represents the year the patient
came to your facility either with a diagnosis of cancer or is diagnosed with cancer
at our facility. Each patient has his or her own unique accession number and, if
that patient should develop a new primary, we would use the patient’s original
accession number for that primary. This will be the only accession number for
that patient, regardless of how many primaries the patient may develop. Check
the PC DaSHw database to determine if the patient has had an earlier primary. If
the patient is recorded in our database, start the patient’s second primary
abstract from that patient record. (The above instructions should have been
completed prior to starting this abstract)

Sequence number should already be entered.

Abstract Date should be an autocode to today’s date.

Medical Record Number: This is the patient’s chart number. Some facilities
use a prefix. If medical record number is unknown enter 999999998.

Military Chart Suffix: Only used at Military Hospitals




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*PRIMARY PAYER: This field refers to type of insurance the patient had at the
time of diagnosis or 1st course treatment. See pages 67-68 in the FORDS
Manual for these codes. Some examples of coding might be:

   Patient has no insurance and will be responsible for payments. Code 02
   HMO/PPO Code 20.
   Code 21 (Private Insurance: Fee-for Service)
   Medicare without supplement would be stated as Medicare only or perhaps
    Medicare part A & B, but no other insurance is noted.
   Medicare with supplement would include our Presbyterian Senior Plan.
   Tricare is the insurance plan for the retired military and their families.

For cases that were diagnosed prior to admission, some Primary Payor codes
that may apply are:

   Veteran’s Affairs (VA) refers to patients who were diagnosed and or treated at
    a VA Hospital
   Code 68 (Indian/Public Health Services or IHS) refers to our Native American
    hospitals and clinics.

DATE OF FIRST CONTACT: This is the date the patient was first seen at your
facility with the mention of cancer. This date may be a lab work-up, a radiology
report, an outpatient biopsy or it may be an admission. If the cancer was
diagnosed at your facility, this date cannot be after the diagnosing date, but must
be prior to or equal to the date of diagnosis. If the cancer was diagnosed at
another facility, prior to being admitted to this facility, this date must be after the
diagnosing date. Please see page 87 in the FORDS manual for description.

       If it is the end or beginning of a calendar year and the patient was
        admitted in December, but was not diagnosed until January and you want
        this case to be reflected in the January statistics, accession the case as a
        January case, using the date of admission as January 1st and the
        accession number would be the January year. The Accession number
        must match the Date of First Contact. If it does not, it will not pass the
        GenEdits.

DATE OF INPATIENT ADMISSION: This is self-explanatory. If the patient was
never admitted, code to zeros.

DATE OF DISCH: If the patient was admitted, use the actual date of discharge. If
the patient was only seen as an outpatient, this date should be the same as the
Date of First Contact.

Facility Referred From: If the patient was diagnosed prior to admission, enter
the facility where he was diagnosed in this field. If this is a class of case 1, code
to 0000


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Facility Referred To: If the patient was diagnosed here and is going elsewhere
to receive his treatment, enter the facility where the patient will be going to
receive treatment. If it is unknown where he will be going, use 9999. If this
abstract is a class of case 1, code to 0000.

Additional Physician Information

Radiation Physician: If the patient received radiation therapy, enter the
radiation physician’s name or the facility where the radiation was given.

Systemic Treatment Physician: If the patient received chemotherapy, enter
the Hem/Onc physician’s name or the facility where the chemotherapy was
given.

Other Physician: Use this field for physicians attending the patient other than
the surgeon, radiation/oncologist or hem/onc physician.

THE SUPPLEMENTAL PAGE MUST BE FILLED OUT BEFORE EDITING THE
ADMISSION PAGE.

SUPPLEMENTAL:
These fields are NMTR’s special fields. These fields are used for Special Study
purposes. Most of this information can be found relatively easy in the physician
notes or lab reports.

Family Hx:
Her2Neu:
Menopausal Status
PSA: (Enter) actual PSA numbers
Smoking Hx:
Alcohol Hx:
Occupation (if unknown type in the word unknown)
Patient on Protocol

Edit both admission and supplemental page now AND GO TO Path Reports
HOSPITAL PATHOLOGY NUMBERS
This field is used to record the pathology accession numbers and dates.
For NMTR, this information is recorded for the use of current and future special
studies, where tissue needs to be banked for research.
HIT Add TO BEGIN (leave this page blank if you do not have a path report)
The Pathology Facility represents the facility where the pathology was read.
Enter the specific facility code where the pathology was read;




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The Pathology Report # represents the accession number of the
pathology/cytology report. Enter that number here. The above examples of
pathology numbers or accession numbers are given above (SPP-07-0000206 is
an accession number)

The Path Date is the date of the pathology report.

The Pathology Procedure represents the method used to obtain the specimen.
The codes are different for specific sites, so use the drop-down box. These are
not found in any of the manuals. They are NMTR’s codes. Pick the method that
best describes the procedure.

Pathology Code represents either the ICD-0-3 code or the text or name of the
histology. If you will be entering the ICD-0-3 code use an H. If you will be writing
out the name (i.e., Adenocarcinoma) use the D. Please use the correct
pathology code letter. If you do not, editing needs to correct.

Pathology Dx: Enter either the description or histology, which every you have
chosen for the pathology code.

Pathology Report Remarks – This Pathology Report Only: If you have any
comments about this pathology report, enter them here.

SAVE at this time

IF YOU HAVE MORE THAN ONE PATHOLOGY REPORT TO ENTER, HIT
ADD NOW. THEN ENTER THE NEXT REPORT USING THE ABOVE
GUIDELINES. ENTER ADD FOR EACH ADDITIONAL REPORT YOU HAVE.

Edit Pathology when you have completed all entries. Move to Treatment

At the top of the page, you will see three tabs. Start on the Treatment Selection
tab.
Treatment Type: There are three codes for this field. These are very important,
because they represent:
01. Treatment & bx’s done at the abstracting facilty (formerly page 4A on the
   old PC DaSH)
02. Treatment & bx’s completed at another facility (formerly page 4B old PC
   DaSH)
05. Subsequent treatment (formerly page 4C)

The treatment Type defaults to the abstracting facility. If no treatment was done
at the abstracting facility, fill with zeros and Add another level for each of the
other treatment types.



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Treatment Facility: If you have coded the Treatment Type to 01, code to the
facility code where you are abstracting. Treatment type 02; code to the facility
where the specific treatment was given. For treatment type 05; code the facility
where the subsequent treatment was given (could be the facility where you are
abstracting if the case is recurrent or has disease progression).

Date Treatment Started is an autocode. Once you have filled out your treatment
fields, the correct date will appear in that box.

Primary Site should already be coded. If this is not the site you wanted, go back
and change the site code on Tumor tab, then to Tumor Identification.

Histology should also be already coded. If this is not what you want, go back
and change it.

Hit Enter and it will then take you to the Treatment Fields

After entering the correct Treatment Type, go to the next tab at the top of the
screen, which is:

*Surgery:   Using the FORDS Manual, code the surgical codes according to the
instructions given. Make sure that the surgery dates match the date of the
pathology report. Many times, these are two different dates. For this facility, we
are using the pathology date as the correct date.

*Date of Surgical Discharge: The date the patient was discharged following
the surgery.

*Readmission to same hospital within 30 days: If the patient was readmitted
here at one of the Pres hospitals, document the proper code as to whether it was
planned or not.
A Narrative box will appear for you to label the types of surgery and the dates
given.
Edit Treatment Surgery

*Radiation and Systemic: Using the FORDS Manual, code the radiation and
systemic treatment fields according to the instructions given.
Pain Assessment: These fields represent whether the chemotherapy, radiation,
or surgery was given for palliative reasons, only. In other words, to just relieve
the pain, not to cure the cancer. Code accordingly.
Edit Radiation and Systemic
For each level, you must Save between each level, then Add the next level.



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Edit All Treatment

Summary Treatment is an autocode.

*RECURRENCE and DATE: If the patient was considered disease free
following his first course of treatment and returns with cancer, this is considered
a recurrence.
To code recurrence, hit the Add button. Then highlight the bar with the arrow
within the box in the upper left hand corner. Using the codes found on page 197
in the FORDS 2007 Manual, code the Recurrence Type the Date of Recurrence
and the Recurrence Sites.
Save and Edit Recurrence
If abstracting at an ACoS facility check with the registrar to see if they collect
Hospital Specific codes.


On the bottom of the screen, you will see Attention: Editing
The information you will place in this narrative will be:
       Native American Tribe information.
        Follow-up physicians that are not listed in PC DaSH or on the physician’s
       list, but are indicated to be a cancer-treatment physician, such as a
       surgeon, oncologist or following physician-. List the physician’s name,
       address & phone number, if you have it. DO NOT ADD RESIDENTS or
       FELLOWS.
      If the medical records indicates the patient was referred to another facility
       for their treatment, enter the name of that facility.
      Any additional information to substantiate your coding.

GO TO DEMOGRAPHICS AND HIT “CHECK EDITS”.
This will give you a screen with five areas of the abstract with an
“Edited” box on the right hand side. If you do not have a check mark
within this box, this means you need to go back to that screen and
edit that screen. The PC DaSH Edit Report will come up showing
you where your errors are. If it says “Good Job”, this means that the
edits just needed to be run and you should now have a check mark
within the box on main edit screen.




                                          22
Surgical Margins of Primary Site:
0. It the patient had surgery (you must have surgery coded in 4A or 4B) and all of
the margins are stated to be negative within the path report, then code to 0.
1. This code would probably be used for a CoC 3, when you don't really know a
whole lot, but information indicates that there could be residual tumor.
2. Microscopic residual means that the pathology from the surgery states that the
margins are POSITIVE. Remember, this means that surgery must be done.
3. Macroscopic residual means that the surgeon went in and couldn't cut out all
of the tumor and he made statements such as, "we had to leave some tumor
behind". or "we debulked MOST of the tumor".
7. Margins not evaluable. This is used for TURB's, TURP's and brain surgery,
when the surgeon takes out the tumor in bits and pieces, so the pathologists
does not have a nice neat mass to evaluate the margins, thus margins are not
evaluable.
8. This is the code that we are having difficult with, because on the drop-down
box, it states "diagnosed at autopsy". But, in reality, this code should be used if
no surgery was done of the primary site. The drop-down box seems to indicate to
use 9 for this, but that is not what the FORDS manual indicates.
9. The following list indicates when you would use this code.
 If it is unknown whether surgery was done or not
 For lymphoma, unless the site is coded to an extranodal site, such as the
    stomach, and surgery was done. Then code accordingly.
 Hematopoietic and leukemia
 Unknown Primary
 Death Certificate Only




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