How Do You Know?

Tips on Medical Record Abstraction

I learned early in my career there really is an answer to virtually every question for abstracting in an approved resource manual. You just have to be persistent and put forth the effort. While answering abstracting questions, many times I am asked, “How do you know?” My initial response is usually that I do not “know” as much as I am a good researcher and with 20+ years of experience I have learned to trust my resources. Those of us that are, let’s say experienced rather than old, remember when there were no electronic resources (only paper manuals lots and lots of manuals). When I started working as a traveling consultant my manuals weighed in excess of 45 pounds. I know this because I learned to pack them very strategically throughout my suitcases so that they were not too heavy to manage. Once I got on-site they were transferred to one rolling case. I would then spend my days shuffling through that genius stack of books and abstracting.

How do I know? I read the manuals. Yes, really, I take the time to read all of the introductions and patter in the beginning of each resource. There is a great deal of information that describes and defines the content. For instance, in the new STORE manual you will find that the STORE 2018 Overview on pages 11 -13 explains not only what you will find in the manual but the rationale for changes and a 2018 Coding Reference List. The list is like a virtual library in 2 vertical inches of white space. Brilliant! Each resource is well titled and immediately shares the type of content you should expect to find.

Once you have a keen knowledge of your individual resources you are more than halfway there! The rest is quite easy. Use the “find” function in the individual electronic manual to locate your topic of interest and then read carefully. Think about it. How do the presenters at the conferences know? They read the manuals and sometimes copy and paste pages into a PowerPoint and read aloud to you. How do the responders in the CAnswer Forum know? They scour the resources and provide an answer based on their findings. How does your QA/PI person know? Because he or she took the time to read and learn the material in the resources. Now YOU know! Take a bit of time to educate yourself. Read your materials before, during and after you abstract. You will be an abstracting mastermind in no time!

2018 Coding Reference List (From STORE Manual – page 12)

AJCC Cancer Staging Manual, Eighth Edition: https://cancerstaging.org/references-tools/Pages/Cancer-

Staging-Resources.aspx

Site-Specific Data Items (SSDIs): https://apps.naaccr.org/ssdi/list/

Grade: https://www.naaccr.org/SSDI/Grade-Manual.pdf

ICD-O-3 Histologies: http://codes.iarc.fr/

SEER Site/Histology Validation List: https://seer.cancer.gov/icd-o-3/

2018 Solid Tumor Coding Rules: https://seer.cancer.gov/tools/solidtumor/

SEER Hematopoietic and Lymphoid Neoplasm Database: https://seer.cancer.gov/tools/heme/

Summary Stage 2018: https://seer.cancer.gov/tools/ssm/

SEER*Rx – Interactive Drug Database: http://seer.cancer.gov/tools/seerrx

 

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