Lesson 2: Reporting Methods and Source Documents Flashcards
(77 cards)
Disease index
The alphabetized list of every patient (alive or dead) discharged from the hospital organized by disease or diagnosis code for a specific time period
Who usually prepares the disease index?
the health information management department
other name for disease index
discharge diagnosis code index
how often should the registry request the previous month’s disease index
once a month
Health Information Management Department
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
When requesting the disease index, the registrar should specify….
the cancer codes used by the HIM department to identify inpatient and outpatient visits
Use of the _____ of ICD-9-CM codes for casefinding will narrow the requested search to appropriate, registry-reportable cases
cancer-screening list
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
cancer committee
Use the casefinding lists to…
screen prospective cases and identify cancer cases for inclusion in the registry
Cancer registries and cancer surveillance programs typically describe the reportable neoplasms as…
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)
/2 behavior code
in situ
/3 behavior code
invasive
/0 behavior code
benign
/1 behavior code
neoplasm
True or False? Cases are abstracted during the casefinding process
False. Abstracting is done at a later time. During casefinding, we are only concerned with identifying cases that are potentially reportable
The first step in casefinding
determine the casefinding sources that are available, and those that are effective for your facility
Casefinding from _____, ______, and ______ are the most widely used in hospital registries.
pathology
medical and radiation oncology
the HIM disease index
Casefinding should encompass…
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
Second step in casefinding
decide how these reports will be reviewed and how registrars will access the information, then decide the frequency in which they are reviewed
The type of review that you do, active or passive, depends on many factors, including:
- the number of cases abstracted each year
- the size of the casefinding logs and reports
you must meet the deadline for abstracting set by who?
your central cancer registry
does the CoC have an abstracting timeliness requirement?
No
Most registries perform casefinding on a ______ basis from the medical record indices (diagnostic index) and treatment logs
monthly