The October CTR Coding Break reviews the topic Abstracting in Text. Text in the cancer abstract is important and must be complete, timely, and accurate in order to be useful. Text can explain the choice of codes and should match the coded data. A brief introduction is provided along with more detail of the multiple subjects of text.
Many times, the date, name or type, and findings will be required to record in text. The slides break down each text field by what to record, a sample of what is found in the electronic medical record, and an example of what the text might look like in the cancer registry abstract. Text can help explain or justify the choice of codes if there are unique situations or questions regarding the coded data.
Proper documentation is both a skill and an art. It is recommended to check your state reporting guidelines for further instruction.
If you would like to download this month’s presentation as a PDF click here.