13.1 The Abstracting Process: Workflow, Source Documents, Timeliness & Text Documentation

The abstracting workflow

1. Case identification. Casefinding (Chapter 9) flags a possible case. Confirm that the tumor is reportable under STORE, SEER or NPCR, and state rules, and that it was diagnosed on or after the reference date.
2. Check the patient index. Search the registry for the patient. If the patient already has an accession number, this tumor gets the same accession number and the next sequence number (Section 11.1).
3. Decide the number of primaries. Apply the Solid Tumor Rules or the Hematopoietic and Lymphoid Neoplasm Coding Manual before coding anything else. A new primary gets a new abstract, and a recurrence is recorded in the follow-up items.
4. Assign Class of Case (Chapter 11). This controls which items CoC requires.
5. Gather source documents from every relevant setting: history and physical, imaging, endoscopy, laboratory, operative and pathology reports, consultations, treatment summaries, and outside records.
6. Code the items. These include demographics, diagnosis (site, histology, behavior, grade, laterality, Diagnostic Confirmation), staging (AJCC, Summary Stage 2018, SSDIs), first-course treatment, and follow-up.
7. Write the text. Document the evidence for each coded item in the NAACCR text fields.
8. Run edits. Correct the errors, apply override flags only when the unusual combination is verified, and let the software set the completion date.

Source documents and what they answer

Official priority lists

When documents disagree, do not rely on a general "most authoritative document" idea. Use the priority list the standard setter publishes for the specific item:

• Histology: each Solid Tumor Rules module gives a priority order for documentation. Tissue from the primary site comes first, and histology is coded from the diagnosis before neoadjuvant therapy. Code the more specific histology when the final diagnosis and the synoptic report differ.
• Grade: the Grade Manual's priority is the synoptic report (CAP protocol), then the final diagnosis, then a physician statement.
• Lymph node counts: STORE's priority is final diagnosis, then synoptic report, then microscopic description, then gross description.
• Primary site: follow ICD-O-3 and the Solid Tumor Rules site instructions. Consult the physician advisor when the record does not identify a site.
• Staging: AJCC rules define which information belongs to the clinical and the pathological time frames. For example, operative findings can support pathological T when the surgeon's resection meets AJCC criteria, and the pathology report does not automatically override every clinical fact.

Timeliness

• CoC Standard 6.1 requires each program's quality control plan to evaluate abstracting timeliness every year, together with casefinding and the percentage of unknown values. The 2020 standards leave the specific timeliness target to the program's plan.
• Date Case Completed–CoC [2092] is set automatically by the registry software once the items required for the case's Class of Case are abstracted and pass the "Hosp: CoC Required - All" edit set. It was created to measure abstracting timeliness and "may also be used as part of CoC Standard 6.1" timeliness monitoring. Follow-up information, delayed treatment and corrections may be added afterward.
• RCRS (Standard 6.4) expects monthly submission of cases to the NCDB, so the registry must keep abstracting current throughout the year.
• State central registries set their own reporting deadlines in law or rule. Many require facilities to report within about six months of diagnosis or first contact; check your state's rule.

Items required by Date Case Completed–CoC

NAACCR text fields

Rules for good text

• Manual entry: NAACCR's rationale says text "must contain a description that has been entered by the reporter independently from the code(s)." Text that software generates from codes cannot be used to check those codes.
• Justify the codes: each text item lists the coded items it should support. For example, RX Text--Surgery supports the surgery, lymph node surgery, margins and sequence items.
• Include dates and sources: for example, "04/02/26 CT C/A/P: 3.1 cm R lower lobe mass, no adenopathy, no mets."
• Use NAACCR-approved abbreviations, and do not repeat the same information in several fields.
• Who uses it: NPCR and SEER list the text fields as required. Central registries use text to consolidate reports from several facilities and for quality control and special studies. STORE notes that text is not transmitted to the NCDB.

Worked example

A right hemicolectomy pathology report shows "adenocarcinoma, 5.2 cm, invades through the muscularis propria into pericolic fat, 0/18 nodes." The operative note mentions "dense adhesions to the retroperitoneum" but no invasion.

• Text--DX Proc--Path: "03/14/26 R hemicolectomy: adenoca, mod diff, 5.2 cm, invades thru MP into pericolic fat; margins neg; LVI absent; 0/18 LN."
• Text--DX Proc--Op: "03/14/26 open R hemicolectomy; dense adhesions to retroperitoneum, taken en bloc; no residual gross disease."
• Coding: because adhesions are not tumor invasion, the pathological T comes from the pathology finding, pT3. That gives Regional Nodes Examined 18 and Positive 00.