AHIMA/NCRA Cancer Registry Management Program PROFESSIONAL PRACTICE EXPERIENCE REQUIREMENT The professional practice experience is the hands-on application of the program coursework. The clinical practice will provide the student with experience in the technical aspects of cancer registry operations and compliment the knowledge gained during the academic portion of their education. The information provided in this packet is a set of resource documents to assist with this endeavor. To qualify for the Certified Tumor Registrars (CTR) certification exam under Eligibility Route A, students must have successfully completed all of the following by the exam s application deadline: 1) A minimum of an Associate degree or equivalent [60 college-level credits]. 2) The AHIMA/NCRA Cancer Registry Management formal education program. 3) 160 hours of work experience in a cancer registry. During the clinical practice, students must be under the direct supervision of an active Certified Tumor Registrar (CTR). When you should begin the PPE requirement: It is the student's responsibility to identify and contact the healthcare providers where the work experience requirement can be completed. Any agreement for the clinical practice should be viewed as an arrangement between the organization and the student. Neither AHIMA nor NCRA assumes responsibility for the student's actions or the clinical experience. It is strongly recommended that you not begin the work experience until you have completed at least the first five specialty courses in the CRM program. The theoretical foundation provided in those courses is essential to understanding the general concepts and principles of cancer registry functions and operations. Additionally, about half of the 160 hours of work experience will focus on abstracting, coding and staging, which are topics covered in these courses. The clinical supervisor will expect the student to have basic knowledge and skills in these areas. You may choose to complete the work experience requirement concurrently with the final specialty course (Follow Up, Data Quality, and Utilization), or wait until you have completed all of the coursework to begin the work clinical practice. Tips for Locating Clinical Host Sites: 1. Don t wait. Begin contacting possible sites before you complete the program. Certain times of the year may be more feasible than others due to surveys and data submission requirements. 2. Begin by contacting hospitals in your area. If they are not available, ask for names of other facilities in the state or region. A list of approved programs in your area can be obtained from the Commission on Cancer Website at: http://www.facs.org/cancerprogram/index.html. 3. Use the NCRA Directory of Mentors/Clinical Site Hosts to identify other possible host sites in your area. The list can be found at: http://www.jobtarget.com/home/index.cfm?site_id=749. 4. Contact the state cancer registrar association for possible names. A list of state association contacts can be found on the NCRA website at: http://www.ncrausa.org/i4a/member_directory/fesearchform.cfm?directory_id=1&pageid=3445&showtitle=1. 5. Contact the state s central cancer registry to see if they are available to host a clinical or for possible location in your area. A list of central cancer registry contact information can be found on the CDC NPCR website at: http://apps.nccd.cdc.gov/cancercontacts/npcr/contacts.asp. 6. If a host cannot accommodate the entire 160 hours, recommend solutions such as sharing time with another facility or the central cancer registry or splitting the session into increments.
Suggestions for acquiring a clinical site and completing the clinical to meet the CTR Exam requirements: 1. Review this packet and the clinical experience requirements. 2. Review the CTR Exam website (http://www.ctrexam.org/) to ensure you have the most current information pertinent to the CTR exam you plan to sit for. 3. Use the Clinical Site Fact Sheet to help gather general information about the clinical site. 4. Customize the Introductory Letter for Professional Practice and mail to the clinical supervisor as soon as they have agreed to host the clinical. This letter should be typed and personalized. Enclose a copy of the enclosures listed at the bottom of the letter. 5. Contact the clinical supervisor at least two weeks prior to the start date. If possible, arrange for a personal visit. When making a personal visit, call the clinical supervisor for an appointment. Confirm the following: a. Start date and reporting time b. Where you should report to c. Employee dress code d. Parking e. Identification f. Coding manuals that will be provided and those you are required to bring 6. Take the enclosed Confidentiality Statement (or the facility s confidentiality statement if they prefer) with you on the first day. Read and sign the confidentiality statement with the clinical supervisor. Confidentiality and HIPAA regulations are a very serious matter. It is very important that you maintain strict confidentiality of any and all information encountered. This includes cancer patient information, health record information and cancer center/facility operation information. Under no circumstances should any documentation or information be discussed or removed from the facility or department. Failure to abide by the confidentiality policies of the facility could result in termination of the clinical practice. 7. Dress in appropriate business attire and according to the employee dress code as you will be expected to attend various meetings. This includes conservative dresses, skirts, blouses, sweaters, and dress slacks for women and dress shirts and slacks for men. 8. Review and adhere to the NCRA Code of Ethics. During the clinical practice, you are considered an employee of the facility in that you must abide by all employee policies and procedures for the cancer registry and the organization. This includes confidentiality, policies and procedures, attendance, dress code, performance and compliance with assigned duties. 9. Report promptly every day. You should adhere to the work schedule set by the clinical site supervisor as if you were a paid employee. If you must be absent from work, it is IMPERATIVE that you notify your clinical supervisor. Absences should be avoided unless there is an illness or emergency. The clinical site supervisor has agreed to volunteer his/her expertise and time to help you complete your clinical. Missed time must be rescheduled which may be difficult depending on the supervisor s availability.
10. The professional practice experience is a working experience. While some activities may only be observed, the intent of the clinical is to be a working, hand-on experience in various activities of the cancer registry. A list of recommended activities has been provided. Some activities are required (see list of abstracting requirements and the clinical hours report). However, the supervisor has the final decision as to what activities will be required to accomplish these requirements. Assigned activities must be completed and be completed to the best of your ability. 11. You have been provided several forms to help track and document your clinical experience. a. Use the Weekly Time Record to help track and document the number of hours worked. b. Use the Clinical Hours Report to help track and document that you have completed all of the requirements for the professional practice experience for the Registry Experience section of the CTR exam application. c. Use the Student Evaluation to receive feedback from the supervisor regarding your professional practice experience. 12. The cancer registry database is the foundation of all registry activities. By allowing you access to the database, the supervisor trusts you to preserve the integrity of the data. Entering false information, changing or deleting information without approval is strictly prohibited. Deletion of an entire case or record should only be performed by the supervisor or with direct supervision. If possible, access rights should not allow for record deletion. 13. Schedule the clinical so that you can attend at least one of each of the following meetings: a. Cancer Committee b. Cancer Committee subcommittee meetings c. Cancer Conference 14. Schedule a closing interview on the last day of your clinical with the clinical supervisor. At this time, you should discuss the supervisor s evaluation and the summaries and copies from any assignments. Any copies of any information from the assignments must be approved by the clinical supervisor before they can be removed from the department. 15. When the clinical has been successfully completed, have the supervisor complete and sign the Supervisor Verification section of the CTR Examination Application. If the application for the exam you are taking is not available, then make arrangements for having it signed when it is available. 16. Promptly send separate thank you notes to your clinical supervisor and all associated staff members. Documentation required to be provided on the CTR exam application: 1. The student must provide PPE information in the Registry Experience section. 2. The supervisor of the cancer registry (clinical supervisor) must complete and sign the Supervisor Verification section. The supervisor is not required to sign the application if all of the requirements for the clinical practice have not been met. Note: AHIMA does not require that any documentation regarding the clinical or the exam be submitted back to AHIMA. The CTR exam application is sent directly to the testing company. The mailing address for the CTR exam application is located in the Candidate Handbook.
AHIMA/NCRA Cancer Registry Management Program PROFESSIONAL PRACTICE EXPERIENCE Clinical Site Fact Sheet Student Name: Facility Name: Address: Supervisor: Supervisor s Credentials: CTR #: I certify that I am an active CTR. Email: Phone #: COC Approval Category: Last COC Survey: Annual Analytic Caseload: Registry s Reference Date: Cancer Committee Frequency: Cancer Conference Frequency: Medical Records (Electronic/Paper): Cancer Registry Software System: How many full time employees (FTEs) are in the Cancer Registry? How many Cancer Registrars have the following specific credentials? CTR? RHIA? RHIT? CCA? CCS?
(Insert Date here) Introductory Letter for Professional Practice (delete this header information) Cancer Registry Management Program Administration American Health Information Management Association 233 N. Michigan Ave. Suite 2150 Chicago, IL 60601 312-233-1100 e-mail: continuing.education@ahima.org (Insert clinical host address here) Dear (Insert Mr./Mrs. Name here): This letter is to introduce, a student enrolled in the AHIMA/NCRA Cancer Registry Management Program. This student is interested in utilizing your facility to obtain professional practice experience in all areas of cancer registry operations and management. The professional practice experience is the hands-on application of the program coursework. The clinical practice will provide the student with experience in the technical aspects of cancer registry operations and compliment the knowledge gained during the academic portion of their education. The student must complete 160 hours in the clinical experience. During the clinical practice, students must be under the direct supervision of an active Certified Tumor Registrar (CTR). This student has completed courses in anatomy and physiology, pathophysiology and pharmacology, medical terminology, microcomputer applications, cancer registry operations, cancer registry structure and management, cancer disease coding and staging, abstracting methods, oncology treatment and coding, and follow-up, data quality and utilization. This student is well prepared to obtain an entry-level position as a cancer registrar and may be a source for a qualified employee in this position following program completion. By agreeing to accept a student for professional practice experience you are agreeing to: A. Provide an opportunity for the student to complete the work hour requirement. B. Provide an opportunity for the student to complete the abstracting requirement. C. Provide an opportunity for the student to participate in or perform the required activities listed on the Clinical Hours Report. D. Complete, discuss and provide a copy of an evaluation to the student at the conclusion of the clinical practice. E. Complete and sign the Supervisor Verification section on the student s CTR exam application provided the student has met the clinical practice requirements. In addition, a list of recommended assignments has been provided. This list provides a guideline that would allow the student to become more knowledgeable of the cancer registry and various cancer registry activities and meet the clinical requirements. However, the final decision as to the required
assignments and what the student is allowed to copy and take with them is at the discretion of the clinical supervisor. Ideally, the clinical experience should start with the following: A general orientation to the facility and cancer center Review of the facility s confidentiality policy Review of the assignments that must be completed during the clinical Review of the student s performance expectations Orientation to the cancer registry software and any other software used by the registry. This student has been informed about respecting the privacy and confidentiality of health information and a confidentiality form has been made available for your use. The student shall be required to sign and abide by the confidentiality statement prior to the start of the clinical practice. Accepting a student from our program should be viewed as an arrangement between your organization and the student. Neither AHIMA nor NCRA assumes responsibility for the student's actions; however, we do appreciate your willingness to advance the professional skills of this student and contribution to the profession through mentoring. Thank you for your consideration. Sincerely, AHIMA/NCRA Cancer Registry Management Program Administration Student Information: Name: Address: Phone: Email: (Insert Student Information) Enclosures: Clinical Hours Report Abstracting Requirements Recommended Assignments for the Hospital Registry Clinical Student Evaluation
AHIMA/NCRA Cancer Registry Management Program PROFESSIONAL PRACTICE EXPERIENCE Confidentiality Statement and Agreement for Professional Practice I,, understand that gaining access to patient records in order to collect data, analyze, and abstract information and assign clinical codes for my own professional practice purposes is a serious matter. As a student cancer registry professional allowed to view records from the facility, I agree to fully respect the rules of confidentiality for both the patient and the healthcare provider. No information will be shared with anyone outside your organization from this experience, including any acknowledgment of the presence of a patient or his/her record in your facility. Student Signature Facility Representative Signature Both parties should discuss and sign this form and each should retain a copy.
AHIMA/NCRA Cancer Registry Management Program PROFESSIONAL PRACTICE EXPERIENCE Abstracting Requirements (Based on the Clinical Requirements for CTR Exam Eligibility) 1. A minimum of 30 abstracts must be completed, this includes: a. Data Collection, ICD-O-3 Coding, Staging (CS, AJCC TNM, SEER Summary), and Treatment b. 80 of the 160 hours must be spent on abstracting (even if more than 30 abstracts need to be completed) c. A minimum of 30 abstracts must be completed (even if more than 80 hours are needed) 2. Review the facility s list of required data items to be collected. 3. Complete at least two abstracts for each of the following primary sites. Other sites may also be abstracted in order to meet the 30 abstract/80 hour minimum. a. Head and Neck b. Colon c. Other Digestive Tract d. Lung e. Melanoma f. Other Musculoskeletal System g. Breast h. Gynecological i. Genitourinary j. Lymphoma k. Leukemia l. Brain m. Unknown/Ill-defined Sites 4. Entering the case into the cancer registry software is preferred, but if not possible, the attached abstracting worksheet may be used. 5. Abstracts should have at least a 90% accuracy rate (or higher as specified by the supervisor) and should be above 95% by the end of the clinical. The abstract must pass all edits. 6. The attached Abstracting Quality Review Form may be used by the supervisor to evaluate abstracting accuracy. Other Required Activities: The remaining 80 hours of the clinical should be spent performing the other activities in the cancer registry. The NCRA Formal Education Guidelines specify the number of hours that must be spent on each activity. The activities and required hours are listed on the Clinical Hours Report provided below.
AHIMA/NCRA Cancer Registry Management Program PROFESSIONAL PRACTICE EXPERIENCE Recommended Assignments for the Hospital Registry Clinical The following is a list of recommended assignments that could be completed during the clinical experience to help meet the requirements for the number of hours required in each category (see the Clinical Hours Report). Other assignments may be assigned by the clinical supervisor. This list provides a guideline that would allow the student to become more knowledgeable of the cancer registry and various cancer registry activities. However, the final decision as to the required assignments and what the student is allowed to copy and take with them is at the discretion of the clinical supervisor. All copies and summaries must be typed and clearly labeled and shared with the clinical supervisor. Copies of summaries and assignments do not need to be returned to AHIMA. Ideally, the clinical experience should start with the following: A general orientation to the facility and cancer center Review of the facility s confidentiality policy Review of the assignments that must be completed during the clinical Review of the student s performance expectations Orientation to the cancer registry software and any other software used by the registry. 1. Complete the Clinical Site Fact Sheet. 2. Obtain (or create if not available) copies of the following organizational charts: a. All positions (including job titles) in the Cancer Registry b. All departments in the Cancer Center, including the Cancer Registry c. The reporting structure of the Cancer Registry (to whom does the Registry report to). 3. Obtain written job descriptions for all positions in the Cancer Registry including the Manager. 4. Request information on the salary range for cancer registry positions at this facility. 5. Request information on how to learn about job opportunities for cancer registrars at this facility. 6. Attend the following meetings held during the clinical. If possible, assist in preparing for the meetings. Obtain a copy of the agenda, meeting schedule and attendee requirements (by title). a. Cancer Committee (should attend at least one) b. Cancer Conference (should attend at least one) c. Cancer Committee subcommittee meetings (recommended but not required). 7. Schedule brief meetings (30 minutes or less) with key members of the cancer program including the cancer committee chair, cancer liaisons, administrators, and subcommittee chairs to discuss their role in the cancer program and challenges to their position. 8. Review each section of the Cancer Registry Policy and Procedure Manual. Discuss any areas that were unclear and any areas that needed updating. Obtain copies of the following: a. Manual s table of contents b. Reportable and non-reportable lists
c. Eligibility and reporting requirements including the central cancer registry and other reportable-by agreement. 9. Review the documentation related to the last CoC survey. Discuss the survey experience including successes, obstacles, and areas needing improvement. 10. Discuss and review what information the cancer registry routinely provides the cancer committee. 11. Obtain copies of letters used by the registry including follow-up and further treatment letters. Create new or updated letters if needed. 12. Generate and mail the next period s follow-up letters. Process incoming follow-up information and update the cancer registry abstract where appropriate. 13. Review and obtain a copy of the most recent annual report or site-specific studies for the cancer program. Assist in generating graphs or writing summaries for the next annual report or site-specific study. 14. Review the Release of Information policy. Run the following reports in the cancer registry software. Unless otherwise specified, generate the report based on the most recent year with complete data. a. Accession register b. Master Patient Index c. Listing of cases in suspense d. Total number of cases by year (all sites) since the registry s reference date (all years) e. Total number of cases by primary site f. Total cases by clinical and pathological AJCC Stage Group for each of the top five sites g. Total number of cases by class of case h. Current follow-up report. 15. Answer the following questions about the registry (run additional reports if necessary) and determine if the activity is in compliance with the standards? Question Total cases in the cancer registry database Total cases in suspense Top five cancer sites abstracted Month currently being abstracted Percent of cases with an unknown primary site Percent of cases with an unknown stage Patients under active follow-up Follow-up letters sent out each month Follow-up rates Cases presented at cancer conference this year Abstracts reviewed by a cancer committee physician this year and the accuracy rate Path reports reviewed for CAP protocol compliance and the compliance rate Medical records reviewed for AJCC Staging compliance and the compliance rate Number of data requests completed each year Number of edits returned by the NCDB that Total Number In Compliance? Y/N/NA Comments / Explanation
required corrections All required areas are documented in the P&P manual and are up-to-date 16. Complete one site specific analysis including survival rates on a site of your choice (cannot be the same as in recent annual reports). You may use the ACS Cancer Facts and Figures as a resource. a. Generate a graph for each of the following: number of cases each year, derived AJCC stage, sex, race, age, subsite (if appropriate) and histology. Use at least three different types of graphs (e.g.: bar, line, pie, etc.) b. Generate a survival graph using at least two different methods (e.g.: observed, adjusted). c. Compare the numbers and rates to state and national figures. d. Write a summary explaining your findings. 17. Inquire about the common types of abstracting errors seen in the data. Run reports to identify and correct these and other data errors. 18. Write a narrative summary of the overall clinical experience and assignments.
AHIMA/NCRA Cancer Registry Management Program PROFESSIONAL PRACTICE EXPERIENCE Weekly Time Record Name of Student: Name of Facility: Use this form to help track and document that you have completed the required 160 hours for the professional practice experience for the Registry Experience section of the CTR exam application. WEEKLY TIME RECORD Date Hours Worked From To Total Hours Comments TOTAL HOURS WORKED Time Absent: Reason(s): This is a correct record of the time worked this week. Date Date Student Signature Clinical Supervisor Signature
AHIMA/NCRA Cancer Registry Management Program PROFESSIONAL PRACTICE EXPERIENCE Clinical Hours Report Student Name: AHIMA ID Number: Use this form to help track and document that you have completed the required activities for the professional practice experience for the Registry Experience section of the CTR exam application. Activity Hours Required Hours Completed Supervisor s Initials Data Collection (Abstracting), includes: 80 ICD-O-3 Coding Staging (CS, AJCC TNM, SEER Summary) Treatment Required Files (Suspense, MPI, P&P, etc.) 8 Follow-up 18 Cancer Committee activities 10 Cancer Conferences 5 Quality Control 8 Reporting 9 Central Registry Reporting 3 Legal Requirements 2 Quality Management Studies 8 Basic Computer Orientation 2 Casefinding 7 Total: 160 Did the student complete a minimum of 30 abstracts? Yes No Did the student spend a minimum of 80 hours on abstracting activities? Yes No Did the student spend a minimum of 160 hours working on the professional practice experience requirements for the CTR Exam eligibility requirements? Yes No General Comments: Date CTR #: Clinical Supervisor Signature I certify that I am an active CTR.
AHIMA/NCRA Cancer Registry Management Program PROFESSIONAL PRACTICE EXPERIENCE Student Evaluation The following student evaluation and assessment document, prepared for the AHIMA/NCRA Cancer Registry Management program, may be used by a sponsoring facility to provide personal feedback to the student. This evaluation is intended for personal use by the student and supervisor, and need not be returned to AHIMA. The student may elect to use this document as a job reference document for future employment. 1. Did the student seem to understand and correctly apply ICD-O coding conventions and principles for diagnoses? If not, what were the concerns or suggestions for correcting deficiencies? 2. Did the student seem to understand and correctly apply case finding conventions and principles for procedure reporting? If not, what were the concerns or suggestions for correcting deficiencies? 3. Was the student s knowledge of data collection methods what you expected for an entry level professional? If not, what were the concerns or suggestions for correcting deficiencies?
Evaluation of the Student 4. Did the student appear to be committed to the profession, conducting him or herself in a professional manner while in your facility? If not, what were the concerns or suggestions for correcting deficiencies? 5. What suggestions would you give this student for enhancing success as a cancer registry management professional? Date Clinical Supervisor Signature Facility Date Student Signature
AHIMA/NCRA Cancer Registry Management Program - Professional Practice Experience Abstracting Worksheet Patient Identification Accession Number Place of Birth: Sequence Number Date of Birth: Age at Dx: Medical Record Number Social Security Number Race 1: 2: 3: 4: 5: Last Name Spanish/Hispanic Origin: Sex: First Name Primary Payer at Dx: Middle Name Comorbidities and Complications: Address at Diagnosis: 1: 6: Patient Address (Number and Street) 2: 7: Patient Address (Number and Street) Supp 3: 8: City/Town, State, Zip Code 4: 9: County at Diagnosis 5: 10: Current Address: Patient Address (Number and Street) Patient Address (Number and Street) Supp City/Town, State, Zip Code Managing Physician Following Physician Primary Surgeon Physician # 3 (Other/Rad Onc) Physician # 4 (Other/Med Onc) Cancer Identification Class of Case Ambiguous Terminology Diagnosis Institution Referred From Date of Conclusive Diagnosis / Flag / Institution Referred To Date of Multiple Tumors / Flag / Date of First Contact / Flag / Mult Tumors Rep as One Primary Date of Initial Diagnosis Multiplicity Counter Primary Site Laterality Histology Behavior Code Grade/Differentiation Grade Path System Grade Path System Value Lymph-Vascular Invasion Diagnostic Confirmation Primary Site Text: Histology Text:
Stage of Disease at Diagnosis Date of Surg Diagnostic and Staging Proc / Flag / SEER Summary Stage 2000 Surgical Diagnostic and Staging Procedure AJCC Clinical Stage: AJCC Pathologic Stage: T: N: M: Stage Group: T: N: M: Stage Group: Collaborative Stage: CS Tumor Size CS SSF 1 CS SSF 9 CS SSF 17 CS Extension CS SSF 2 CS SSF 10 CS SSF 18 CS TS/Ext Eval CS SSF 3 CS SSF 11 CS SSF 19 CS Lymph Nodes CS SSF 4 CS SSF 12 CS SSF 20 CS Lymph Nodes Eval CS SSF 5 CS SSF 13 CS SSF 21 Reg LN Examined CS SSF 6 CS SSF 14 CS SSF 22 Reg LN Positive CS SSF 7 CS SSF 15 CS SSF 23 CS Mets at Dx CS SSF 8 CS SSF 16 CS SSF 24 CS Mets Eval CS SSF 25 CS Mets at DX Bone Brain Liver Lung Physical Exam: Text Lab Tests: Pathology: Scopes: Operative Procedures: Staging: Place of Diagnosis: X-Rays/Scans: Remarks:
First Course of Treatment Date of First Course of Treatment / Flag / Radiation Therapy: RX Summ-Treatment Status Date Radiation Started / Flag / Location of Radiation Treatment Surgery: Radiation Treatment Volume Date of First Surgical Procedure / Flag / Regional Treatment Modality Date Most Def Surg Resection of Prim Site/Flag / Regional Dose: cgy Surgical Procedure of Primary Site Boost Treatment Modality Approach - Surg of Primary Site This Facility Boost Dose: cgy Surgical Margins of the Primary Site Number of Treatments to This Volume Scope of Regional Lymph Node Surgery Radiation/Surgery Sequence Surgical Procedure/Other Site Date Radiation Ended / Flag / Date of Surgical Discharge / Flag / Reason for No Radiation Readm to Same Hosp w/in 30 Days of Surg Disch Reason for No Surgery of Primary Site Systemic Therapy: Date Systemic Therapy Started / Flag / Date Chemotherapy Started / Flag / Palliative Care Chemotherapy Date Hormone Therapy Started / Flag / Hormone Therapy Date Immunotherapy Started / Flag / Abstracted By Immunotherapy Hematologic Transplan/Endocrine Proc Systemic/Surgery Sequence Other Treatment: Date Other Treatment Started / Flag / Other Treatment Facility Identification Number (FIN) Case Administration Surgery: Treatment Text Radiation: Chemotherapy: Hormone/Steroid: Immunotherapy: Transplant/Endocrine: Other Therapy:
Re-Abstracting Audit Abstractor: Date: Facility: PATIENT IDENTIFICATION Name Address at DIAGNOSIS Social Security Number Date of Birth Race 1-5 / Spanish Origin Sex Comorb/Comp 1-10 CANCER IDENTIFICATION Class of Case Date of First Contact Date of Initial Diagnosis Sequence Number Primary Site Laterality Histology/Behavior Grade Diagnostic Confirmation MPH Data Items (2007 and after) Physicians Med Rec # TOTAL +'s TOTAL +'s % Correct This Page All Pages (each item) STAGING INFORMATION Date of Surg Dx & Staging Proc Surgical Diag & Staging Proc CS Tumor Size CS Extension CS Tumor Size/Ext Eval CS Lymph Nodes CS Reg Nodes Eval Regional Nodes Positive Regional Nodes Examined CS Mets At Diagnosis CS Mets Evaluation CS Site Specific Factors 1-25 OTHER DATA ITEMS Target Percent = 95% Results = % (-) Indicates item is incorrect. Refer to comments explaining the disagreement(s). Charts reviewed: Page #:
Re-Abstracting Audit Abstractor: Date: Facility: TREATMENT Date 1 st Course Of Rx Date of First Surgical Proc Date Most Def Surg Resx Prim Surgery of Primary Site Surgical Margins of Primary Site Scope of Reg Lymph Node Surg Surgical Procedure/Other Site Reason For No Surg of Prim Site Date Radiation Started Regional Treatment Boost Treatment Radiation Surgery/Sequence Date Radiation Ended Reason For No Radiation Med Rec # TOTAL +'s TOTAL +'s % This Page All Pages Date Systemic Therapy Started Chemotherapy Hormone Therapy Immunotherapy Hemat Trans/Endocrine Proc Systemic Surgery/Sequence Other Treatment Palliative Care OUTCOMES/CASE ADMINISTRATION Recurrence Information Follow-Up Information TEXT Should include: date, procedure, location and results where known. OTHER DATA ITEMS Site Code: TOTAL +'s (55 possible) % CORRECT (each abstract) Instructions: For each data item, place a "+" if the abstracted information is correct. Place a "-" if the abstracted information is incorrect. The form is designed to calculate the accuracy rate by the abstract (each column) and by the data item (each row). Note: Many data items were grouped. For example, all SSF's were grouped under one heading. All regional radiation treatment related data items are grouped under one heading "regional treatment". All date fields would include the corresponding flag field. This form can be modified by adding or deleting data items as needed at your facility. To calculate the % Correct for each abstract: Divide the total number of +'s received by the total number of +'s possible. This form is designed to add or change the data items to be checked. There are currently 55 data items (or groups of data items) listed for review. Example: If 52 of the 55 data items were correct, this would be 52/55 or 95% Correct. To calculate the % Correct for each data item: Total the number of +'s received for each data item. Divide the total number of +'s by the total number of +'s possible. This form is designed to record up to 5 abstract reviews per page. This form can also be used to combine reviews from multiple pages. Example: 15 charts were reviewed. For the data item "Name", 14 of the 15 abstracts were correct. 14/15 = 93% Correct. Target Percent = 95% Results = % (-) Indicates item is incorrect. Refer to comments explaining the disagreement(s). Charts reviewed: Page #:
Reviewer: Abstractor: Re-Abstracting Audit SUMMARY Facility: Date: Number of Charts Reviewed: Total (this number is also the total possible Correct correct for each data item) (+'s) % Correct Comments (areas below 95%) PATIENT IDENTIFICATION Name Address at DIAGNOSIS Social Security Number Date of Birth Race 1-5 / Spanish Origin Sex Comorb/Comp 1-10 CANCER IDENTIFICATION Class of Case Date of First Contact Date of Initial Diagnosis Sequence Number Primary Site Laterality Histology/Behavior Grade Diagnostic Confirmation MPH Data Items (2007 and after) Physicians STAGING INFORMATION Date of Surg Dx & Staging Proc Surgical Diag & Staging Proc CS Tumor Size CS Extension CS Tumor Size/Ext Eval CS Lymph Nodes CS Reg Nodes Eval Regional Nodes Positive Regional Nodes Examined CS Mets At Diagnosis CS Mets Evaluation CS Site Specific Factors 1-25 OTHER DATA ITEMS Target Accuracy Percent: 95% To calculate % Correct, divide total correct by total possible.
Reviewer: Abstractor: TREATMENT Date 1 st Course Of Rx Date of First Surgical Proc Date Most Def Surg Resx Prim Surgery of Primary Site Surgical Margins of Primary Site Scope of Reg Lymph Node Surg Surgical Procedure/Other Site Reason For No Surg of Prim Site Radiation Date Radiation Started Regional Treatment Boost Treatment Radiation Surgery/Sequence Date Radiation Ended Reason For No Radiation Systemic Therapy Date Systemic Therapy Started Chemotherapy Hormone Therapy Immunotherapy Hemat Trans/Endocrine Proc Systemic Surgery/Sequence Other Therapy Other Treatment Palliative Care OUTCOMES/CASE ADMINISTRATION Recurrence Information Follow-Up Information TEXT Re-Abstracting Audit SUMMARY Total Incorrect % Correct Facility: Date: Comments OTHER DATA ITEMS Total Accuracy Percent: Instructions: Use this form to summarize the findings from the re-abstracting review. Use the comments as a learning opportunity for the student by providing information on common errors, why the item was marked incorrect, etc. Note: Many data items were grouped. For example, all SSF's were grouped under one heading. All regional radiation treatment related data items are grouped under one heading "regional treatment". All date fields would include the corresponding flag field. This form can be modified by adding or deleting data items as needed at your facility. Target Accuracy Percent: 95% To calculate % Correct, divide total correct by total possible.