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Breast Abstracting in Honor of National Breast Cancer Awareness Month
Breast Abstracting

To commemorate National Breast Cancer Awareness Month I’d like to start a supportive conversation about our breast abstracting processes. Hopefully I can even encourage a few experienced abstractors to share their best practices with newer ones like me by leaving a comment below. Let me get started…

Breast abstracting intimidated me at first because there were so many facets to consider. For example, all of those CS data items, the neoadjuvant treatment and so many options for radiation and/or chemotherapy combinations, plus the hormone treatment after everything else. Many of my breast cases also had to be placed on my treatment follow up log because they were usually not finished with treatment by the time I was abstracting the case, which was another confounding factor for me.

I was lucky enough to have a mentor (shout out to Ms. Kara Zeinner – thank you so much!) who taught me her breast abstracting method when I was doing my very first cases. Even though I tweaked it a little for myself, I found it to be very efficient. I’m going to share it with all of you…

1. Open a Word document and add the patient’s name and MR number at the top. As if you’re going through your record, add patient demographics such as age, race, alcohol and tobacco, occupation and emergency contact, all right there in your first paragraph. Since every facility has its own requirements for what to put in an abstract, this is just an example of what I add. Feel free to tweak my method and make it your own.

2. Jot down DOLC, DOA and DOD on the very next line. While you look for admission and discharge dates, you can also pull up any co-morbids the patient has and insurance information from the coding summary.

3. Go straight to the path report in the patient’s EMR. Record everything you intend to put in your abstract’s text fields in your already open Word document.

4. Open coding software (we use Oncolog) and check to see if the case has already been abstracted. The last thing we want as CTRs is to code a case that has already been completed and sent. If your case needs attention, continue recoding info in your Word document.

5. From the path report, record the ER, PR and HER2 status, along with the KI-67 and Magee IHC4 Mammaprint and/or Oncotype scores. Look for the surgery that belongs to the path report, again recording exactly what the surgeon said the surgery was and also the date of admission and surgical discharge. If you have a surgical patient then you need to check for clinical and pathological tumor measurements.

6. Open your HP to check why the surgery was done, recording everything as it will be in the text sections in your abstract. Also look for a family history of breast cancer to put in this section.

7. Record whatever radiology you need to. Sometimes it’s a mammogram or breast ultrasound with a tumor measurement or a breast biopsy, sometimes it’s a positive PET scan showing mets.

8. Skip over to the progress notes section of the EMR to look for nursing navigator notes. These will usually tell you what treatment to look for. While you scan, also make note of chemotherapy or radiation treatment. If you find reference to things you need to include in your breast abstract, jot them down as a heading (e.g., “chemo tx – find this” or “PET scan – where/when?”). You don’t always fill the headings out right away, but if you see the patient had that treatment that’s a good reminder for you to go back and find this information in the record. Usually radiation therapy treatment notes and oncology consultations give the most thorough history for patients. Use them to double check your dates for treatment and diagnosis.

9. Check the discharge summary and office notes for the patient. Did they have further treatment elsewhere? Do you need to record any CP3R measures in your text for them? When you review your document, does it tell the story of why they came in, what they had and how they were treated? Do you have the correct class of case assigned with the correct referrals and date of first contact? If not, continue making passes until your documentation tells the most up-to-date cancer story of the patient. Finally, ensure all PHI is not saved and all information collected is only documented in the registry software.

So there you have it, my method for abstracting breast cases. I’d love to hear from my fellow abstractor family about how they prepare their own breast cases. Please leave a comment below to share your process!
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