Text area for manual documentation from the history and physical examination about the history of the current tumor and the clinical description of the tumor.

Text documentation is an essential component of a complete electronic report and is heavily utilized for quality control and special studies. Text is needed to justify coded values and to document supplemental information not transmitted within coded values. High-quality text documentation facilitates consolidation of information from multiple reporting sources at the central registry.

The text field must contain a description that has been entered by the reporter independently from the code(s). If software generates text automatically from codes, the text cannot be utilized to check coded values. Information documenting the disease process should be entered manually from the medical record and should not be generated electronically from coded values.

Instructions

• Prioritize entered information in the order of the fields listed below.
• Text automatically generated from coded data is not acceptable.
• NAACCR-approved abbreviations should be utilized (see Appendix G).
• Do not repeat information from other text fields.
• Additional comments can be continued in empty text fields, including Remarks. For text documentation that is continued from one text field to another, use asterisks or other symbols to indicate the connection with preceding text.
• If information is missing from the record, state that it is missing.
• Do not include irrelevant information.
• Do not include information that the registry is not authorized to collect.

Note: For software that allows unlimited text, NAACCR recommends that the software indicate to the reporter the portion of the text that will be transmitted to the central registry.

Suggestions for text:

• Date of physical exam
• Age, sex, race/ethnicity
• History that relates to cancer diagnosis
• Primary site
• Histology (if diagnosis prior to this admission)
• Tumor location
• Tumor size
• Palpable lymph nodes
• Record positive and negative clinical findings. Record positive results first
• Impression (when stated and pertains to cancer diagnosis)
• Treatment plan

Data Item(s) to be verified/validated using the text entered in this field
After manual entry of the text field, ensure that the text entered both agrees with the coded values and clearly justifies the selected codes in the following fields:

Item name	Item number
Date of Diagnosis	390
Primary Site	400
Laterality	410
Histologic Type ICD-O-3	522
Grade	440
Collaborative Stage variables	2800-2930
Diagnostic confirmation	490
RX Hosp--Surg Prim Site	670
RX Hosp--Scope Reg LN Sur	672
RX Hosp--Surg Oth Rg/Dis	674
RX Summ--Surg Prim Site	1290
RX Summ--Scope Reg LN Sur	1292
RX Summ--Surg Oth Reg/Dis	1294
SEER Summary Stage 2000	759
SEER Summary Stage 1977	760
Regional Nodes Positive	820
Regional Nodes Examined	830
RX Date Surgery	1200
Reason for No Surgery	1340
RX Summ--Surg/Rad Seq	1380
RX Summ--Systemic/Sur Seq	1639
Summary Stage 2018	764
AJCC TNM Data Items	1001-1036
EOD Data Items	772-776
Site-specific SSDI Data Items	3801-3937