Missouri cancer registry
case completeness/ data quality audits
Audit Data Submission Instructions
- PREPARE THE INITIAL DATA FILES:
- Electronic Medical Record Disease Index (see chart and format description below).
- Hospital Admission Type/Service code key.
- Accession Register for the audited year.
Medical Record Disease Index
Refer to the ICD-9-CM Audit Casefinding List for case selection criteria. Refer to the following chart to determine the months to be included in the data sampling for your hospital, based on number of annual cases.
Format of MRDI:
The medical record disease index must include cases from the following sources: inpatients, outpatient/ambulatory surgery, hospital outpatient or clinic visits for chemotherapy, radiotherapy or other definitive cancer treatment. Do not include patient visits for labwork or radiology.
Generate the index in an Excel file and run as a single report, rather than individual monthly reports. Include patient’s last name, first name, date of birth, admission/discharge dates, admission type/service codes, medical record number and at least the top five ICD-9-CM diagnosis and procedure codes, listing them in the order in which they were originally coded. Sort alphabetically, listing all patient encounters for the specified months under the name (see MRDI example). Important: MRDI’s sorted other than alphabetically will not be acceptable. If your departmental program does not have the capability to generate reports in Excel, collaborate with your IS department to run the report in the requested format. We are
available to speak directly to the IS staff to answer anyquestions.
- PATHOLOGY
Pathology review will be performed on-site on the date specified in the initial letter. Contact the pathology department for the requested reports and schedule a room for the auditor for the day of the site visit.Provide pathology reports to include histology, cytology (excluding pap smears), peripheral blood smears, bone marrow biopsies and autopsies (ALL reports for the time period – not just those thatare malignant). Refer to the table below and provide reports for the specified months based on your hospital’s annual reportable caseload.Please note that the months requested are alternate to the months requested for the MRDI. Provide a quiet location with an electrical outlet. If review will be conducted electronically have the specified reports queuedand ready for the auditor.
Missouri cancer registry
case completeness/ data quality audits
Initial Data Submission Instructions
3. DATA QUALITY
Twenty abstracts will be randomly selected from your hospital’s most recent transmission(s).
The text will be reviewed and fifteen data elements re-coded in an effort to duplicate the
abstractor’s codes. The abstractor’s codes will then be reviewed and evaluated for accuracy.
The fields to be re-coded are: diagnosis date, sequence number, primarysite, laterality, histology, behavior, grade, CS extension, CS lymph nodes, CS mets, date of first course of therapy, rx summary surgery primary site, rx summary radiotherapy, rxsummary chemotherapy, rx summary hormone therapy.
It is not necessary to submit any records for the re-coding audit. All data will be provided and reviewed from your hospital’s file in MCR’s master database.
4. DATA SUBMISSION:
- The medical record disease index is to be submitted via Secure File Uploader in WebPlus through your existing user account on the MCR website, Submit the file in the Non-NAACCR format along with a transmittal form, completing the hospital information section at the top and, in the Non-NAACCR section, place an ‘x’ in the box for MRDI and record the name of the file.
- Use the same method to submit the accession register and the admission type/service code key, marking the appropriate boxes and recording the filenames.
- On the Audit Checklist formmark off the initial documents, enter the corresponding dates - your role in the initial process is finished. You will be contacted at a later date for the resolution component of the audit.
Revised June 2009
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