Self Instructional Manual for Cancer Registrars. Abstracting a Medical Record: Patient Identifications, History and Examinations. Book Five. Second Edition

摘要

In this segment of instruction you will begin to learn where to find pertinent information in the medical record and how to record it on your cancer register abstract. When you finish Book 5, you should have an understanding of the usual methods and procedures used to diagnose cancer as well as an understanding of precisely what should be recorded on your registry abstract. Section B is concerned with the composition and organization of a medical record. Sections C, D, E, F, and G are concerned with general to specific instructions for abstracting a medical record. Over 50 sample diagnostic, operative, and pathologic reports are included to teach you how to abstract pertinent information from similar reports in your medical records.