Surgery Text Requirements: Date and type of each surgical procedure (incl. excisional biopsies and surgery to other/distant • sites). Document if lymph nodes, regional tissues or metastatic sites were removed; if so, document LN • number or site. Facility where each procedure was performed. • Positive and negative findings. Record positive findings first. • Other treatment information, e.g., planned procedure aborted; unknown if surgery performed. • Beam Radiation Text Requirements: Date beam radiation began or reason why it was not given (patient refused, patient died, • contraindicated, etc.). Where beam radiation was given; e.g., at this facility; at another facility. • Type of beam radiation as defined in the FORDS Manual (Photons [MV range], Orthovoltage, • Cobalt-60, IMRT, etc.). Beam Radiation Text Recommendation: Other treatment information; e.g., patient discontinued after 5 treatments; unknown if radiation • treatment was given. Non-Beam Radiation Text Requirements: Date non-beam radiation began or reason why it was not given (patient refused, patient died, • contraindicated, etc.). Where non-beam radiation was given; e.g., at this facility; at another facility. • Type of non-beam radiation; e.g., High Dose rate brachytherapy, seed implant, Radioisotopes • (I-131). Non-Beam Radiation Text Recommendation: Other treatment information; e.g., unknown if radiation was given. • Chemotherapy Text Requirements: Date chemotherapy began or reason why it was not given (patient refused, patient died, • contraindicated, etc.). Where chemotherapy was given; e.g., at this facility; at another facility. • Type of chemotherapy, e.g. name of agent(s) or protocol. • Chemotherapy Text Recommendation: Other treatment information; e.g., treatment cycle incomplete; unknown if chemotherapy was given. • Hormone Text Requirements: Date hormone therapy began or reason why it was not given (patient refused, patient died, • contraindicated, etc.). Where hormone therapy was given; e.g., at this facility; at another facility. • Type of hormone or antihormone, e.g., Tamoxifen. •
Surgery Text Requirements: • Date and type of each surgical procedure (incl. excisional biopsies and surgery to other/distant sites). • Document if lymph nodes, regional tissues or metastatic sites were removed; if so, document LN number or site. • Facility where each procedure was performed. • Positive and negative findings. Record positive findings first. • Other treatment information, e.g., planned procedure aborted; unknown if surgery performed. Beam Radiation Text Requirements: • Date beam radiation began or reason why it was not given (patient refused, patient died, contraindicated, etc.). • Where beam radiation was given; e.g., at this facility; at another facility. • Type of beam radiation as defined in the FORDS Manual (Photons [MV range], Orthovoltage, Cobalt-60, IMRT, etc.). Beam Radiation Text Recommendation: • Other treatment information; e.g., patient discontinued after 5 treatments; unknown if radiation treatment was given. Non-Beam Radiation Text Requirements: • Date non-beam radiation began or reason why it was not given (patient refused, patient died, contraindicated, etc.). • Where non-beam radiation was given; e.g., at this facility; at another facility. • Type of non-beam radiation; e.g., High Dose rate brachytherapy, seed implant, Radioisotopes (I-131). Non-Beam Radiation Text Recommendation: • Other treatment information; e.g., unknown if radiation was given. Chemotherapy Text Requirements: • Date chemotherapy began or reason why it was not given (patient refused, patient died, contraindicated, etc.). • Where chemotherapy was given; e.g., at this facility; at another facility. • Type of chemotherapy, e.g. name of agent(s) or protocol. Chemotherapy Text Recommendation: • Other treatment information; e.g., treatment cycle incomplete; unknown if chemotherapy was given. Hormone Text Requirements: • Date hormone therapy began or reason why it was not given (patient refused, patient died, contraindicated, etc.). • Where hormone therapy was given; e.g., at this facility; at another facility. • Type of hormone or antihormone, e.g., Tamoxifen.