Ensuring Quality Control through Defensive Abstracting

Defensive AbstractingDo you have confidence in your cancer registry data? What about the text? Is your cancer registry text complete, accurate and legible? It should be. If the coding used in an abstract is questioned, the only way to “defend” it is through complete and thorough text; this is known as defensive abstracting.

State Cancer Registries are required to support all codes in an abstract with text. According to the North American Association of Central Registries (NAACCR) standards: Text should be included in the registry’s data set and transmitted along with codes when tumor records are shared with other registries. And now, more than ever, State Central Registries are rejecting incomplete abstracts until the data can be verified.

How Your Practice Can Reduce Data Entry Mistakes Using Defensive Abstracting

Defensive abstracting includes supplemental strong text fields that tell the patient’s full story, allowing abstracts to stand alone. It puts the focus on complete documentation (text) to support all fields (codes) and should always document the resource type, date of diagnosis, location of event, type of event, who performed the service and a summary of the event.

But, no matter how experienced or novice a CTRS, mistakes can happen. While not intentional, they can still happen. The reality is that taking the time to do things right the first time will not only result in a high-quality outcome, but also take significantly less time than having to do things over.

A few defensive abstracting tips to keep in mind:

  • Use approved abbreviations and spell them correctly
  • Be brief, but complete
  • If information is not available from the record, state that it is missing
  • Confirm and support all documentation by identifying the source
  • Document, document, document

As a critical component of a complete electronic abstract for state registries in relation to case consolidation processes, defensive abstracting is also essential when consolidating multiple facility databases.

ONCO Software Solutions for Improving Quality Patient Care

At ONCO, we promote defensive abstracting to ensure a process that is accurate and quality-controlled. Our seamless software solutions allow cancer organizations to complete a comprehensive documentation within the abstract, quickly track coded fields and analyze information. Learn more about how ONCO’s suite of solutions can help you in your efforts to improve cancer care through defensive abstracting. Contact us today at 800-604-7538 to schedule your complimentary demonstration.

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