Chart Profile

• Use collection date from the original pathology/cytology taken at diagnosis.
• Do not use the date of pathology/cytology of recurrence or later metastatic site.
• Must have original diagnostic pathology/cytology report in order to abstract chart.
• You may use a report found in a physician note if it is copy/pasted from the original pathology/cytology report.

• Use collection date of original pathology and cytology (if both are positive but have different dates, enter both if prior to treatment). 
• Pathology/cytology reports do not have to come from the practice/health system we are abstracting for and may be found anywhere in the record.
• Abstractors may use a report found in a physician note if it is copy/pasted in its entirety from the original pathology/cytology report.

• Fine needle aspiration (FNA), peripheral blood smear, and flow cytometry are considered cytology.

• Bone marrow biopsies are considered hemato-pathology.

Determining eligibility for End of Life charts

Use the End of Life criteria (patient must have died within the chart abstraction criteria dates; patient must have known date of death; death related to cancer or cancer-related treatment; patient must have 2 office visits with practitioner within 12 months preceding death) to determine if patient qualifies.

For End of Life charts, you may abstract a diagnosis made at any time, even if the patient had a recurrence, if the patient meets the chart selection criteria, however you must have the original diagnostic pathology/cytology report in order to abstract the chart. You may use a report found in a physician note if it is copy/pasted in its entirety from the original pathology/cytology report.

If the patient did not die of cancer or cancer-related treatment or the cause of death is unknown, you may still be able to abstract the patient if patient meets the “alive” chart selection criteria (diagnosed within chart abstraction criteria dates; first office visit with chart abstraction criteria date; 2 office visits within chart abstraction dates). For this option you would choose Cause of Death: “Patient is deceased as a consequence of another disease or cause” OR “Patient is deceased and cause is unknown”.

• If the first visit is with an APP, it MUST BE COMPLETED OR COSIGNED BY THE PHYSICIAN.
• If the patient has a hospital consultation with a practice physician (with a complete History & Physical) and treatment is initiated, use the date of the inpatient consultation as the first office visit date.
• Do not include visits for a chemo teach unless the teach is done as part of a regular visit with a provider.

Please refer to the current Chart Selection Criteria for the appropriate dates.

• Use the date of the most recent practitioner visit.
• Include office and telehealth visits.
• Do not include hospital visits.

Please refer to the current Chart Selection Criteria for the appropriate dates.

• Use the date of the most recent practitioner visit.
• Include office and telehealth visits.
• Do not include hospital visits.