CCR Innovations | Volume 2 | Issue 1 - page 4

Donna M. Hansen, CTR 
Auditor/Training Coordinator
ProducƟon AutomaƟon & Quality Control 
California Cancer Registry 
California Cancer ReporƟng and Epidemiologic Surveillance (CalCARES) Program  
InsƟtute for PopulaƟon Health Improvement  
UC Davis Health System 
California Cancer Registry
Volume 3, Issue 1
Text documentaƟon is an essenƟal component of a complete abstract. While this topic 
is frequently addressed by visual editors, recent California Cancer Registry (CCR) data 
quality audits revealed that insufficient text documentaƟon on the abstract conƟnues 
to be a “missing link” which warrants revisiƟng this topic.  
Why is text needed? Text provides the paƟent’s cancer informaƟon in a readable format. It is necessary to 
support coded informaƟon on the abstract, to document unusual occurrences, and to verify edit checks. 
Text also provides informaƟon for recoding audits, researcher use, facility use, and re‐abstracƟon of 
historical data for comparisons.  
Here are a few general guidelines about text documentaƟon. 

Text fields must contain supporƟng informaƟon entered by the abstractor independently from 
the coded data. 

Text should document the paƟent’s cancer journey from diagnosis through treatment. 

Text should document the When, What, Where and Who as it pertains to the site‐specific 
cancer diagnosis. 

Only approved abbreviaƟons should be used on the abstract.  See Volume 1 Appendices M.1 
and M.2 (links below).   

Appendix M.1   Common Acceptable Symbols and AbbreviaƟons in Term Order 

hƩp://www.ccrcal.org/PAQC_Pubs/V1_2014_Online_Manual/index.htm

Appendix M.2 Common Acceptable Symbols and AbbreviaƟons in AbbreviaƟon Order 

hƩp://www.ccrcal.org/PAQC_Pubs/V1_2014_Online_Manual/index.htm
IdenƟfying the site‐specific informaƟon to record on the abstract and the most concise way to document 
informaƟon is the challenge for cancer registrars. I would like to introduce you to a terrific text 
documentaƟon resource developed by Meryl Leventhal, MA, CTR, Data CollecƟon Manager from the Los 
Angeles Cancer Surveillance Program, Keck School of Medicine at the University of Southern California. 
Meryl gave a presentaƟon at the AbstracƟng 101 Boot Camp which was a preconference workshop as part 
of the California Cancer Registrar’s AssociaƟon Annual EducaƟon Conference this past November. In this 
resource, Meryl provides step‐by‐step guidelines for text documentaƟon with specifics including what 
informaƟon to select from the medical record, what informaƟon to record on the abstract, and the format 
for recording the informaƟon concisely. 
This document is a wonderful stand‐alone‐resource that both new and experienced cancer registrars 
will find beneficial and worthy of inclusion in your personal collecƟon of abstracƟng resources!
Click
here
 to view “
Text DocumentaƟon EssenƟals
” by Meryl Leventhal, MA, CTR 
It all Hinges on TEXT
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