Vol. 19 • Issue 12 • Page 19
To defend is to maintain in the face of argument. To defend your cancer data is to CYA-cover your abstract. In today’s fast-paced environment, we are all striving to be as efficient as possible. So let’s revisit an old friend called defensive abstracting.
What is defensive abstracting?
It is the practice of text field glorification. It is supporting all codes and dates with supplemental text details that tell the full patient story, including information on primary, histology, staging workup, extent of disease and first course of treatment. Defensive abstracting is an essential component of quality control and is very valuable when performing special studies, as it allows the abstract to stand alone. By practicing defensive abstracting, you are documenting supplemental information, which can be used to easily justify coded values.
For example, the abstract states: “Date of Diagnosis: 1/1/2001,” but that isn’t quite enough to understand the complete patient story. A defensive abstract would include additional patient details in the text field, such as: “X-rays: 1/1/2001; Mammo-new .5 cm lesion RUOQ breast suspicious for malignancy.” This abstract’s text field now explains the basis for the diagnosis date, the primary site and the clinical size of the tumor and thus gives a more complete patient story.
How do you document effectively?
It’s important to document positive findings first, abbreviate as much as possible, and use the North American Association of Central Cancer Registries (NAACCR) abbreviations, which can be found at http://www.lcra-usa.org/forms/NAACCR_Abbreviation_List.doc.
NAACCR Standards for Cancer Registries Volume II is a valuable resource for determining what text should be documented and what fields can be validated by the individual text fields. Remember, the goal is to look at a patient’s abstract and understand the full story of the workup, diagnosis and treatment of each patient’s primary, and where the individual procedures were performed.
Now that you have a better understanding of what defensive abstracting is and have gained some helpful tips for practicing defensive abstracting, let’s spend some time understanding why it is practiced.
Why practice defensive abstracting?
First and foremost, perfecting the practice of defensive abstracting allows you and others in your cancer program to have more confidence in the data. By enhancing the completeness of your abstract’s text fields, you are better positioning your abstract for Cancer Program Practice Profile Reports (CP3) reconciliation. Registrars in Commission on Cancer (CoC) accredited programs are required to review CP3 data and identify missing information from patients who do not meet the National Quality Forum (NQF) quality measures used by the National Cancer Data Base (NCDB). If the registrar does not practice defensive abstracting, there is no additional text documented in the abstract, which means extra work re-pulling files and diving back into that patient’s abstract. However, if the registrar documents information as he or she abstracts, the amount of extra work is decreased and the accuracy and completeness of data can be leveraged to justify the coded fields to the cancer committee.
Another example of when defensive abstracting practices are beneficial is during quality review. A physician reviewer may disagree with a coded field in the abstract; however, the physician only has the medical record as their source for confirmation. If a secondary source was used, say a study or dictation from outside the medical record, this should be documented in the text field. If it is documented, it will be much easier for you to defend your abstract when the physician reviewer asks you to explain.
Quality control of registry data is key to having confidence in your data, and if you don’t have confidence in your registry data, no one else will. Another quality control recommendation is for someone in the registry to perform a visual review of cases. Don’t rely solely on the physician 10 percent review. If you are abstracting defensively and using complete text fields, internal quality control is much more convenient and effective.
Cancer registrars know that finding complete diagnostic, treatment and follow-up information often requires searching multiple sources and different software systems, and frequently seeking information from outside of the hospital’s patient record. Defensive abstracting means that you record all information, as well as the source of that information within the registry abstract. This may sound labor intensive, but it’s actually saving you time. You have to look for the information to complete the abstract, so why not document the information within the abstract rather than rely on your memory or an educated guess when questions arise?
The bottom line is if you abstract defensively, you should be able to use the patient abstract as the primary source for reconciling and/or supporting outliers of national treatment guidelines, rather than having to review the entire medical record a second time.
I have presented this defensive abstract concept at numerous registrar meetings with positive feedback. The following is a comment from Karen E. Servacek, CTR, oncology information coordinator, Grand View Hospital, after attending a presentation:
“Each time I’ve entered a case over the last few weeks I’ve recalled your presentation and want you to know how valuable
your information is for all registrars. I believe you shared similar information at a National Cancer Registrars Association meeting.
I took your model of ‘defensive’ abstracting to heart and have shared the concept with many new registrars. Thank you so much-the careful, supportive documentation has not only saved me grief when I had to validate information later, but it has made me more confident and proud of creating a clear and complete snapshot of all of the information relevant to the patient’s cancer diagnosis and management.”
Theresa Gerboc works as a cancer registry specialist at CHAMPS Oncology Data Services, a Cleveland-based cancer registry and cancer program consulting and management company. She has been in the cancer registry profession for 23 years and has been a CTR for 19 years. She has filled a variety of roles, from cancer registry clerk and abstractor to manager/mentor.
