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Data Standards and Data Dictionary

* indicates required field

Length: 4000
Source of Standard: NPCR
Section Name: Text-Diagnosis
Record Types: A, M

XML NAACCR ID: textStaging

Parent XML Element: Tumor

Required Status:

NPCR Collect: R^ - Required, these text requirements may be met with one or several text block fields
CoC Collect: . - No recommendations
SEER Collect: R - Required
CCCR Collect: . - No recommendations

Description:

Additional text area for staging information not already entered in other Text fields.

Rationale:

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), including clinical procedures, that provided information for assigning stage
  • Organs involved by direct extension
  • Size of tumor
  • Status of margins
  • Number and sites of positive lymph nodes
  • Site(s) of distant metastasis
  • Physician's specialty and comments

Format:

Free text

Item Data Type:

text

Allowable Values

Neither carriage return nor line feed characters allowed

Code Notes:

Data Item(s) to be verified/validated using the text entered in this field
After manual entry of the text field, ensure that the text entered both agrees with the coded values and clearly justifies the selected codes in the following fields:

Item name Item number
RxDate Dx/Stg Proc 1280
Collaborative Stage variables 2800-2930
SEER Summary Stage 1977 760
SEER Summary Stage 2000 759
Regional Nodes Positive 820
Regional Nodes Examined 830
RX Hosp--Surg Prim Site 670
RX Summ--Surg Prim Site 1290
RX Hosp--Scope Reg LN Sur 672
RX Summ--Scope Reg LN Sur 1292
RX Hosp--Surg Oth Rg/Dis 674
RX Summ--Surg Oth Reg/Dis 1294
Mult Tum Rpt as One Prim 444
Lateraltiy 410