Lesson 2: Reporting Methods and Source Documents Flashcards
(77 cards)
1
Q
Disease index
A
The alphabetized list of every patient (alive or dead) discharged from the hospital organized by disease or diagnosis code for a specific time period
2
Q
Who usually prepares the disease index?
A
the health information management department
3
Q
A
4
Q
other name for disease index
A
discharge diagnosis code index
5
Q
how often should the registry request the previous month’s disease index
A
once a month
6
Q
Health Information Management Department
A
The part of a healthcare facility that gathers, analyzes, and stores the medical documents for each patient, ensuring completeness and coding, and indexing the records for future reference
7
Q
When requesting the disease index, the registrar should specify….
A
the cancer codes used by the HIM department to identify inpatient and outpatient visits
8
Q
Use of the _____ of ICD-9-CM codes for casefinding will narrow the requested search to appropriate, registry-reportable cases
A
cancer-screening list
9
Q
If the ______ wants additional types of cases included in the registry, the appropriate diagnostic codes for these case types should be added to the screening list
A
cancer committee
10
Q
Use the casefinding lists to…
A
screen prospective cases and identify cancer cases for inclusion in the registry
11
Q
Cancer registries and cancer surveillance programs typically describe the reportable neoplasms as…
A
any neoplasm with a behavior code (fifth digit in a complete six-digit morphology code) of /2 or /3
(some registries also collect and report /0 and /1)
12
Q
/2 behavior code
A
in situ
12
Q
/3 behavior code
A
invasive
13
Q
/0 behavior code
A
benign
14
Q
/1 behavior code
A
neoplasm
15
Q
True or False? Cases are abstracted during the casefinding process
A
False. Abstracting is done at a later time. During casefinding, we are only concerned with identifying cases that are potentially reportable
16
Q
The first step in casefinding
A
determine the casefinding sources that are available, and those that are effective for your facility
17
Q
Casefinding from _____, ______, and ______ are the most widely used in hospital registries.
A
pathology
medical and radiation oncology
the HIM disease index
18
Q
Casefinding should encompass…
A
all points of service through which a patient may enter the health care delivery system for diagnostic and/or therapeutic services for the management of cancer
19
Q
Second step in casefinding
A
decide how these reports will be reviewed and how registrars will access the information, then decide the frequency in which they are reviewed
20
Q
The type of review that you do, active or passive, depends on many factors, including:
A
- the number of cases abstracted each year
- the size of the casefinding logs and reports
21
Q
you must meet the deadline for abstracting set by who?
A
your central cancer registry
22
Q
does the CoC have an abstracting timeliness requirement?
A
No
23
Q
Most registries perform casefinding on a ______ basis from the medical record indices (diagnostic index) and treatment logs
A
monthly
24
If the registry is abstracting on a more concurrent basis, the ______ reports become the main source of casefinding, and will be needed on a daily or weekly basis
pathology
25
All potential cases identified from these reporting sources are entered in the registry’s ______.
suspense system
26
The suspense system is...
a compilation of the cases from all your casefinding sources into one list
(usually a feature of the cancer registry's software system)
27
Cases are abstracted by the date of _____, with the _____ cases first
first contact; oldest
28
cases may remain in ______ for several months until you get to that point in your abstracting
the suspense system
29
True or False? All cases in the suspense system will be abstracted.
False. Not all cases in the suspense system will be abstracted. The casefinding process will also identify cases that are not reportable
29
cases meeting the eligibility requirements for the registry are...
abstracted and added to the cancer registry database
30
cases that are not eligible for inclusion are...
deleted from the suspense system
31
If you can’t decide if the case is reportable...
there is no harm in leaving the case “in suspense” to be scrutinized later
32
HIM plays a large role in identifying cancer cases by accessing information from what sources?
- Pathology
- Treatment
- Disease Index
33
______ is undisputedly the primary source for cancer casefinding.
Pathology
Typically, more than 90% of cases are histologically confirmed.
34
Most registrars ____ review every pathology report, including malignant and non-malignant reports, to determine which cases will potentially be included in the cancer registry.
actively
35
There are multiple types of pathology reports, including:
- surgical specimens
- cytology
- bone marrow biopsies
- autopsy reports
36
______ areas of your facility can be an important source of casefinding, particularly when there are patients referred from other facilities which do not have these capabilities.
Treatment
37
treatment areas include
- Medical Oncology
- Radiation Oncology
38
Medical Oncology
where patients receive chemotherapy, immunotherapy, and other types of systemic drug treatment
39
Radiation Oncology
where patients receive radiation treatments
40
Radiation Oncology departments have unique reports that are usually dictated by the radiation oncologist. These include...
- New patient consult
- Simulation and treatment plan
- End of Treatment (EOT) summary
41
Medical and Radiation Oncology departments usually keep a _____ of all patients seen for the first time in their department
log
* Some may also keep a daily log for every patient seen on a particular day
* You can compare this log to your other casefinding reports to identify those cases whose only contact with your facility was through one of these treatment facilities
42
Simulation and treatment plan
If the patient agrees to treatment, then the next report details the simulation and treatment plan, which outlines the planning that is done prior to treatment, in order to calculate the treatment fields and dosage to be given.
43
End of Treatment (EOT) summary
The final treatment summary is dictated at the end of treatment, describing the start and end dates of treatment, the treatment field, the dosage, the number of treatments, and the number of elapsed days from beginning to end of treatment.
44
New patient consult
details the symptoms, history, diagnostic workup, staging, and treatment recommendations
45
There may be other types of reporting sources available in your facility, such as:
- Nuclear medicine
- Radiology logs and reports
- Operating room schedules
* However, these (^^^) additional casefinding sources are more difficult and time consuming because usually there is not an accurate means of narrowing down the list to those related to cancer
46
Nuclear medicine
a potential source for patients treated with radioactive isotopes. A review of their treatment log will identify other potential cases
46
Radiology logs and reports
can identify patients diagnosed on CT scan, MRI, ultrasound, or mammogram in addition to those who had a CT guided needle biopsy or stereotactic biopsy and received no other care at the facility.
47
The disease index includes...
- medical record number (MRN)
- patient name
- admission and discharge dates
- discharge disposition (to indicate if the patient was released to another hospital or a nursing home)
- at least five diagnosis codes (to provide more info regarding the patient's reason for hospitalization)
47
The disease indices’ most important use is identifying cases that are not found through other means. This includes:
- Cases that are clinically diagnosed
- Cases that are not seen for treatment
-Cases that are only seen for treatment, not diagnosis
- Cases that will only be given supportive care, not cancer directed treatment
- Cases already in the registry database that are returning to the facility for an unrelated reason
- Visits that should be reviewed to ensure that there is not a reportable condition or a missed case, such as a history of cancer
48
The _____ produced by the HIM department is the most common source for identifying cancer cases not found through other means
disease index
49
Cases that are clinically diagnosed
- These cases will not have a pathology report and will only be identified on the indices.
- Cases that are often diagnosed clinically may include the liver, pancreas, lung, brain, and unknown primaries, but any case could be clinically diagnosed
50
Cases that are only seen for treatment, not diagnosis
These cases may have outside pathology reviewed in your pathology department, but depending on the way your facility operates, you might not receive these reports in the registry.
51
Cases that are not seen for treatment may not have a ___ report
pathology
52
True or False? Each patient should only be entered once into the suspense system.
True. However, each patient may have one or more cases listed
(depending on ICD-10-CM coding, whether there are multiple primary sites, and whether there are secondary (metastatic) sites)
52
most cancer registrars usually start the casefinding process with the other resources, such as _____ and _____, and reserve _____ for their final review
pathology reports; radiation oncology logs; the disease index
* Any cases not identified by these other methods, as well as updating the patient’s cancer abstract for follow-up purposes, can be done at this time.
53
Cases that will only be given supportive care, not cancer directed treatment
will not appear in casefinding treatment logs.
53
Cancer registry software has casefinding capability, in which _______ are created through an electronic process.
suspense reports
* This process identifies all cases in your facility that have been assigned one or more ICD-10-CM codes for malignancy, no matter their entry point within your facility.
54
The disease index is generated based on...
specific diagnostic codes
55
In _____, the United States officially transitioned to ICD-10-CM
October 2015
56
_____ provides a ICD-10-CM casefinding list used by most facilities
NCI
"Comprehensive ICD-10-CM Casefinding Code List for Reportable Tumors"
57
Some facilities assign certain codes slightly different. For this reason, both codes should be included in _____ and reviewed for eligibility
the disease index
* For example, if a re-excision for a melanoma is performed as the definitive treatment and the pathology report showed no residual disease, the visit may be assigned a Z85 code (personal history of malignant neoplasm) as opposed to a C43 code (melanoma of the skin)
57
When requesting a disease index… be sure to ask for a list that not only includes _____, but one that also includes the next _____ codes (or as many as your program will allow) listed as _____.
a principle diagnosis of cancer; five; a secondary diagnosis
* Also, all visit types should be included, not just inpatient and one day surgery codes. This is the best way to ensure you are capturing any clinically diagnosed cases.
58
The _____ will include several codes, including diseases that are not cancer-related, and therefore not on the casefinding list (pneumonia, for example).
health record
* Registrars can determine from the diagnosis list why the patient was seen at the facility, and why that patient appeared on the disease index
59
What are three types of casefinding methods used by cancer registries?
- active
- passive
- or a combination
60
The type of casefinding method used varies depending on....
the casefinding source
61
Registries most often utilize _____ casefinding, since cancer registrars are the authorities on the rules for case inclusion.
active
62
____ casefinding relies on other departments to identify the cases and send the results to the registry.
Passive
63
Active casefinding major concerns
accuracy and completeness
64
True or False? Active casefinding is less time consuming
False. Active casefinding is more time consuming
65
Casefinding from pathology reports utilizing the _____ method requires the registrar to obtain copies of all pathology reports, either in paper form or electronically. The registrar would then review all the reports, and personally choose the appropriate cases.
active
66
Casefinding from pathology reports, by the _____ method, requires someone in the pathology department to make decisions regarding which cases to give to the registry
passive
* This can be done by the pathologist dictating a code or some other type of information identifying the case for the registry
* There may be other personnel in the department who are qualified to identify the cancer cases
* It can also be done electronically by having a software program search the final diagnosis for keywords
67
Combination of active and passive casefinding can be seen most easily in...
radiation oncology
* Many registrars rely on that department to send consults and treatment summaries on their patients (passive casefinding). But then the registrar may check radiation oncology’s new patient log at the end of the year to ensure that no patients were missed (active casefinding).
68
Casefinding for a population-based registry is aimed at...
identifying every resident with a reportable diagnosis within the registry's coverage area
69
Facilities that report only to the central registry do not have to meet _____ cancer program standards, so are only concerned with the central registry requirements. Therefore, most of these facilities do not conduct _____.
CoC; follow-up (or track down information from other facilities)
70
the majority of the central cancer registry's casefinding efforts are spent trying to obtain the other 20% of cases from other sources. The other 20% come from a variety of sources including:
- Other states for residents who may have elected to be treated at a facility in another state (this is called data exchange agreements among states)
- Non-registry hospitals
- Free-standing facilities and clinics
- Physicians' offices
- Pathology Laboratories
- Nursing Homes and Hospice
- Death Certificates
