MedPartners ODM Division

Certified Trauma Registrars (CTRs) fall in five categories – Those that:Certified Trauma Registrars (CTRs) fall in five categories – Those that:

  1. Understand the requirements for text and always strive to provide it.
  2. Understand the requirements for text and provide as little as possible, which is often incorrect.
  3. Understand the requirements for text and don’t care.
  4. Do not understand the requirements so they re-write the medical record in the abstract.
  5. Those that simply do not understand the requirements for text, but do their best.

Which one are you?

As a CTR, you know you are required to validate your codes with text. You know you must also provide text to supplement information that is not transmitted with coded values. This is required in each and every state. There are no exceptions.  So why is it that this seems to be such a challenge?

Some reasons I have been given:

  • I am a professionally trained CTR, if someone doesn’t trust my coding they can read the medical record to prove otherwise.
  • Why bother coding if we have to provide all this text. Can’t they just read the text?
  • No one reads the text anyway.
  • We only have to provide it so the State Registry doesn’t have to use their funding for on-site audits.
  • How will they know the difference? We could provide incorrect text to support incorrect codes.
  • Medical billing coders don’t have to; why do we?
  • Soon we are going to be replaced by computers submitting data from the diagnosis and procedure codes, AJCC Staging, SNOMed Coding and written expressions turned to codes. Text won’t be required then, so what is the difference?

OK, so I will admit that I have thought and said two or three of these reasons in my career.

I get it.We all know this is a data quality requirement. At what point is failing to provide proper text a concern for blatant insubordination or reason for termination?  At what point does a State Registry have the right to refuse to accept abstracts from a specific CTR, hospital or vendor? These are real possibilities.

If a State Registry decided to stop accepting abstracts completed by you and shared your name with other states via a NAACCR or SEER database would you change your documentation?

Jennifer Rohleder BS, CTR
Compliance Director, Oncology Data Management and Accreditation Services

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