Version 24
Data Item #2570: Text--DX Proc--Path

Text area for manual documentation of information from cytology and histopathology reports.

Text documentation is an essential component of a complete electronic report and is heavily utilized for quality control and special studies. Text is needed to justify coded values and to document supplemental information not transmitted within coded values. High-quality text documentation facilitates consolidation of information from multiple reporting sources at the central registry.

The text field must contain a description that has been entered by the reporter independently from the code(s). If software generates text automatically from codes, the text cannot be utilized to check coded values. Information documenting the disease process should be entered manually from the medical record and should not be generated electronically from coded values. 

Instructions

• Prioritize entered information in the order of the fields listed below.
• Text automatically generated from coded data is not acceptable.
• NAACCR-approved abbreviations should be utilized (see Appendix G).
• Do not repeat information from other text fields.
• Additional comments can be continued in empty text fields, including Remarks. For text documentation that is continued from one text field to another, use asterisks or other symbols to indicate the connection with preceding text.
• If information is missing from the record, state that it is missing.
• Do not include irrelevant information.
• Do not include information that the registry is not authorized to collect.

Note: For software that allows unlimited text, NAACCR recommends that the software indicate to the reporter the portion of the text that will be transmitted to the central registry. 

Suggestions for text:

• Date(s) of procedure(s)
• Anatomic source of specimen
• Type of tissue specimen(s)
• Tumor type and grade (include all modifying adjectives, i.e., predominantly, with features of, with foci of, elements of, etc.)
• Gross tumor size
• Extent of tumor spread
• Involvement of resection margins
• Number of lymph nodes involved and examined
• Record both positive and negative findings. Record positive test results first.
• Note if pathology report is a slide review or a second opinion from an outside source, i.e., AFIP, Mayo, etc.
• Record any additional comments from the pathologist, including differential diagnoses considered and any ruled out or favored

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