http://caisis.org/wiki/index.php?title=Sample_Prostate_Data_Entry_Guide&feed=atom&action=historySample Prostate Data Entry Guide - Revision history2024-03-28T23:08:46ZRevision history for this page on the wikiMediaWiki 1.15.1http://caisis.org/wiki/index.php?title=Sample_Prostate_Data_Entry_Guide&diff=1168&oldid=prevRobye: /* General Guidelines */2009-09-14T19:49:39Z<p><span class="autocomment">General Guidelines</span></p>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:*'''REV''' - Source documentation reviewed at the hospital available in EMR under "OutsideCorres" folder, official reports such as path reports, lab reports, pathology specimens or slides reviewed at the hospital.</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:*'''REV''' - Source documentation reviewed at the hospital available in EMR under "OutsideCorres" folder, official reports such as path reports, lab reports, pathology specimens or slides reviewed at the hospital.</div></td></tr>
<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:*'''STD''' - All original hospital documentation including dictated initial consults, clinic forms, diagnostic and pathology reports</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:*'''STD''' - All original hospital documentation including dictated initial consults, clinic forms, diagnostic and pathology reports</div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:*'''RR''' – Data reviewed for research by Attending Pathologist (Only for Prostate pathology results).</div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:*'''RR''' – Data reviewed for research by <ins class="diffchange diffchange-inline">the </ins>Attending Pathologist (Only for Prostate pathology results).</div></td></tr>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Allergies==</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Allergies==</div></td></tr>
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</table>Robyehttp://caisis.org/wiki/index.php?title=Sample_Prostate_Data_Entry_Guide&diff=1167&oldid=prevRobye: /* General Guidelines */2009-09-14T19:49:20Z<p><span class="autocomment">General Guidelines</span></p>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:One of the most important tools is the Electronic Medical Record (EMR). EMR is where you can find a scanned copy of forms and other documentation. Here you can zoom in on forms and try to take a closer look at the writing. Occasionally and depending on the doctor, you can find a dictation of the same form in EMR allowing you to easily understand what is written on the form. If you enter the first few letters or approximate spelling of a medication name and hit search, you can usually find the right spelling and a description of the medication. </div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:One of the most important tools is the Electronic Medical Record (EMR). EMR is where you can find a scanned copy of forms and other documentation. Here you can zoom in on forms and try to take a closer look at the writing. Occasionally and depending on the doctor, you can find a dictation of the same form in EMR allowing you to easily understand what is written on the form. If you enter the first few letters or approximate spelling of a medication name and hit search, you can usually find the right spelling and a description of the medication. </div></td></tr>
<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div><p></p></div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div><p></p></div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:For items written in the Medical & Surgical History / Comorbidities section doing a web search can provide clues to what the doctor wrote if you are not certain. Another great resource is of course your co-workers. Some <del class="diffchange diffchange-inline">RSA’s </del>are used to an individual doctor's hand writing and may be able to help make out ambiguous items. If you are unable to definitively make out hand writing do not enter what you think it might say. Speak to your RDC or contact the person (ie. Attending or Fellow) who wrote down the items in question to find the answer.</div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:For items written in the Medical & Surgical History / Comorbidities section doing a web search can provide clues to what the doctor wrote if you are not certain. Another great resource is of course your co-workers. Some <ins class="diffchange diffchange-inline">RSAs </ins>are used to an individual doctor's hand writing and may be able to help make out ambiguous items. If you are unable to definitively make out hand writing do not enter what you think it might say. Speak to your RDC or contact the person (ie. Attending or Fellow) who wrote down the items in question to find the answer.</div></td></tr>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:Once you have entered data and want to save the form you need to always enter the Data Quality when it is available. You will have four options to select from. They are as follows:</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:Once you have entered data and want to save the form you need to always enter the Data Quality when it is available. You will have four options to select from. They are as follows:</div></td></tr>
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</table>Robyehttp://caisis.org/wiki/index.php?title=Sample_Prostate_Data_Entry_Guide&diff=1166&oldid=prevRobye: /* Introduction */2009-09-14T19:48:04Z<p><span class="autocomment">Introduction</span></p>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>[[Category:Training]]</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>[[Category:Training]]</div></td></tr>
<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>=Introduction=</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>=Introduction=</div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:This guide was made in order to help new and current <del class="diffchange diffchange-inline">RSA’s </del>efficiently and precisely enter prostate patient information from the clinic or surgery forms into Caisis in an approved and standardized method. This guide is also intended to enable other <del class="diffchange diffchange-inline">RSA’s </del>who generally enter data for other urological cancers to be able to enter prostate patient data as well. In the event prostate data accumulates and <del class="diffchange diffchange-inline">RSA’s </del>responsible for its entry are not able to enter it within four weeks other <del class="diffchange diffchange-inline">RSA’s </del>can refer to this guide and assist in entering the data to ensure completion in a timely fashion. It is the goal of this guide to ensure a standard of prostate data entry and procedures for issues that may arise due to discrepancies on forms, medical records, and et cetera.</div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:This guide was made in order to help new and current <ins class="diffchange diffchange-inline">RSAs </ins>efficiently and precisely enter prostate patient information from the clinic or surgery forms into Caisis in an approved and standardized method. This guide is also intended to enable other <ins class="diffchange diffchange-inline">RSAs </ins>who generally enter data for other urological cancers to be able to enter prostate patient data as well. In the event prostate data accumulates and <ins class="diffchange diffchange-inline">RSAs </ins>responsible for its entry are not able to enter it within four weeks other <ins class="diffchange diffchange-inline">RSAs </ins>can refer to this guide and assist in entering the data to ensure completion in a timely fashion. It is the goal of this guide to ensure a standard of prostate data entry and procedures for issues that may arise due to discrepancies on forms, medical records, and et cetera.</div></td></tr>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>=Follow Up and New Visit Forms=</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>=Follow Up and New Visit Forms=</div></td></tr>
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</table>Robyehttp://caisis.org/wiki/index.php?title=Sample_Prostate_Data_Entry_Guide&diff=1156&oldid=prevRobye: /* Medications */2009-09-14T19:09:25Z<p><span class="autocomment">Medications</span></p>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Medications==</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Medications==</div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:Under the Therapies tab click on Medications. Enter each medication and the date when the patient started taking it from the form, dictation, or medication reconciliation list. For a new visit or initial <del class="diffchange diffchange-inline">dictaion</del>, if there is no date on any of these documents enter “PreTx”, meaning the patient began taking the medication prior to treatment. If a new medication is listed during a follow up visit, then enter the date of the visit as the start date for that medication. Many times medications are difficult to read so check if there is a dictation for that visit explaining the medications. You can also try entering the first few letters of the medication to generate a drop down list. After completing the '''Date''', '''Medication''', '''Dose''', and '''Schedule''' fields, select the appropriate '''Data Source''' (ie. Data Form / Medical Record / Medication Reconciliation) and '''Data Quality'''. If you do not have the original prescription order the '''Data Quality''' will be '''OUT'''.</div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:Under the Therapies tab click on Medications. Enter each medication and the date when the patient started taking it from the form, dictation, or medication reconciliation list. For a new visit or initial <ins class="diffchange diffchange-inline">dictation</ins>, if there is no date on any of these documents enter “PreTx”, meaning the patient began taking the medication prior to treatment. If a new medication is listed during a follow up visit, then enter the date of the visit as the start date for that medication. Many times medications are difficult to read so check if there is a dictation for that visit explaining the medications. You can also try entering the first few letters of the medication to generate a drop down list. After completing the '''Date''', '''Medication''', '''Dose''', and '''Schedule''' fields, select the appropriate '''Data Source''' (ie. Data Form / Medical Record / Medication Reconciliation) and '''Data Quality'''. If you do not have the original prescription order the '''Data Quality''' will be '''OUT'''.</div></td></tr>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Chemotherapy & Hormone Therapy==</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Chemotherapy & Hormone Therapy==</div></td></tr>
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</table>Robyehttp://caisis.org/wiki/index.php?title=Sample_Prostate_Data_Entry_Guide&diff=1148&oldid=prevRobye: /* Pathology */2009-09-14T18:07:55Z<p><span class="autocomment">Pathology</span></p>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:<p>g) '''Pathologist'''</p></div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:<p>g) '''Pathologist'''</p></div></td></tr>
<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:<p>h) '''Data Source''' </p></div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:<p>h) '''Data Source''' </p></div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:<p>i) '''Data Quality'''(RR if Path report is done by <del class="diffchange diffchange-inline">Drs. Reuter or Olgac</del>)</p></div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:<p>i) '''Data Quality'''(RR if Path report is done by <ins class="diffchange diffchange-inline">Attending Pathologist</ins>)</p></div></td></tr>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>===Prostatectomy Pathology===</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>===Prostatectomy Pathology===</div></td></tr>
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</table>Robyehttp://caisis.org/wiki/index.php?title=Sample_Prostate_Data_Entry_Guide&diff=1147&oldid=prevRobye: /* Prostatectomy Findings */2009-09-14T18:07:14Z<p><span class="autocomment">Prostatectomy Findings</span></p>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>===Prostatectomy Findings===</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>===Prostatectomy Findings===</div></td></tr>
<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:This sub form will appear below the main procedure record if you followed the instructions stated above. If it is not on the same page as your previously entered procedure record, click on the "SubForms" button and select Prostatectomy Findings.</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:This sub form will appear below the main procedure record if you followed the instructions stated above. If it is not on the same page as your previously entered procedure record, click on the "SubForms" button and select Prostatectomy Findings.</div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:This sub form corresponds to the section labeled Intraoperative Prostate Exam on the surgery details form filled out by the physician. Enter one row for each site mentioned on the form. The numbers printed on the form correspond to codes located to the left of the Intraoperative <del class="diffchange diffchange-inline">Prosate </del>Exam box on the surgery details form.</div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:This sub form corresponds to the section labeled Intraoperative Prostate Exam on the surgery details form filled out by the physician. Enter one row for each site mentioned on the form. The numbers printed on the form correspond to codes located to the left of the Intraoperative <ins class="diffchange diffchange-inline">Prostate </ins>Exam box on the surgery details form.</div></td></tr>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Pathology==</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Pathology==</div></td></tr>
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</table>Robyehttp://caisis.org/wiki/index.php?title=Sample_Prostate_Data_Entry_Guide&diff=1146&oldid=prevRobye: /* General Guidelines */2009-09-14T18:05:01Z<p><span class="autocomment">General Guidelines</span></p>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>=Prostate Cancer Surgeries and Procedures=</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>=Prostate Cancer Surgeries and Procedures=</div></td></tr>
<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==General Guidelines==</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==General Guidelines==</div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:To find the list of surgeries you are responsible for go to the prostate data entry folder on the share drive <del class="diffchange diffchange-inline">(H:\DataMgmt\ProstateDataEntry)</del>. Some attendings enter parts of the surgeries they perform directly into Caisis using e-forms. Others will fill out the surgery details form for you to collect and use to enter data. In either case you need to make sure the surgeries you are responsible for have been properly entered into Caisis with a lag time no greater than four weeks. You can find out whether or not you need to collect surgery detail forms by asking your RDC.</div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:To find the list of surgeries you are responsible for go to the prostate data entry folder on the <ins class="diffchange diffchange-inline">hospital </ins>share drive. Some attendings enter parts of the surgeries they perform directly into Caisis using e-forms. Others will fill out the surgery details form for you to collect and use to enter data. In either case you need to make sure the surgeries you are responsible for have been properly entered into Caisis with a lag time no greater than four weeks. You can find out whether or not you need to collect surgery detail forms by asking your RDC.</div></td></tr>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==OR Details Record==</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==OR Details Record==</div></td></tr>
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</table>Robyehttp://caisis.org/wiki/index.php?title=Sample_Prostate_Data_Entry_Guide&diff=1145&oldid=prevRobye: /* Prostate Biopsies */2009-09-14T18:00:01Z<p><span class="autocomment">Prostate Biopsies</span></p>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Prostate Biopsies==</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Prostate Biopsies==</div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:To completely enter a prostate biospy you need to enter a procedure record, a pathology record using the outside institution's findings, and a pathology record using <del class="diffchange diffchange-inline">MSKCC</del>'s reviewed findings.</div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:To completely enter a prostate biospy you need to enter a procedure record, a pathology record using the outside institution's findings, and a pathology record using <ins class="diffchange diffchange-inline">the hospital</ins>'s reviewed findings.</div></td></tr>
<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>===Procedure Record===</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>===Procedure Record===</div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:Begin by selecting Procedures under the Procedures tab. Always enter the '''Date''', '''Institution''', '''Data Source''' and '''Data Quality'''. '''Data Quality''' will always be ''OUT'' for prostate biopsies done outside even if they have been reviewed and are avaialable in EMR. For the '''Procedure''' field you can enter "Needle Biopsy", "TRUS Biospy", or "TURP". Nearly all prostate biospies performed at <del class="diffchange diffchange-inline">MSKCC </del>will be a TRUS biospy, containing a pathology report and TRUS data form in EMR. Most of the outside biospies will be Needle biopsies. Also be sure to enter "Prostate" in the '''Site''' field for each prostate biopsy.<p></p></div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:Begin by selecting Procedures under the Procedures tab. Always enter the '''Date''', '''Institution''', '''Data Source''' and '''Data Quality'''. '''Data Quality''' will always be ''OUT'' for prostate biopsies done outside even if they have been reviewed and are avaialable in EMR. For the '''Procedure''' field you can enter "Needle Biopsy", "TRUS Biospy", or "TURP". Nearly all prostate biospies performed at <ins class="diffchange diffchange-inline">the hospital </ins>will be a TRUS biospy, containing a pathology report and TRUS data form in EMR. Most of the outside biospies will be Needle biopsies. Also be sure to enter "Prostate" in the '''Site''' field for each prostate biopsy.<p></p></div></td></tr>
<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>===Pathology Record(s)===</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>===Pathology Record(s)===</div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:Next under the Procedures tab go to the Pathology sub menu and select Prostate Biopsies. If a prostate biopsy is performed outside and it has been reviewed by a <del class="diffchange diffchange-inline">MSKCC </del>pathologist, you will need to enter two pathology records; one from the outside report and one from <del class="diffchange diffchange-inline">MSKCC </del>review. Make sure to connect each pathology record to the procedure record by choosing the corresponding '''Source Procedure''' in the drop down list.<p></p></div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:Next under the Procedures tab go to the Pathology sub menu and select Prostate Biopsies. If a prostate biopsy is performed outside and it has been reviewed by a <ins class="diffchange diffchange-inline">hospital </ins>pathologist, you will need to enter two pathology records; one from the outside report and one from <ins class="diffchange diffchange-inline">hospital </ins>review. Make sure to connect each pathology record to the procedure record by choosing the corresponding '''Source Procedure''' in the drop down list.<p></p></div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:For the top main portion of the form enter fields '''Path Report Date''', '''Path #''' (aka Accession #), '''Specimen Type''' (same as the procedure name), '''Site''', '''Result''', '''Institution''' (where the specimen was reviewed), '''Pathologist''', '''Data Source''' and '''Data Quality''' (Datat Quality is always OUT for data from outside reports). If the report was done or reviewed by <del class="diffchange diffchange-inline">Dr. Reuter </del>enter ''RR'' (aka Reviewed for Research) for '''Data Quality'''<p></p></div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:For the top main portion of the form enter fields '''Path Report Date''', '''Path #''' (aka Accession #), '''Specimen Type''' (same as the procedure name), '''Site''', '''Result''', '''Institution''' (where the specimen was reviewed), '''Pathologist''', '''Data Source''' and '''Data Quality''' (Datat Quality is always OUT for data from outside reports). If the report was done or reviewed by <ins class="diffchange diffchange-inline">the Attending Pathologist </ins>enter ''RR'' (aka Reviewed for Research) for '''Data Quality'''<p></p></div></td></tr>
<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:On the Prostate Biospy sub-form always enter the fields '''# Positive Cores''', '''Total # Cores''', '''# Positive Sites''', and '''Total # Sites'''. If the biopsy has a Gleason Grade, enther the '''Primary''' and '''Secondary Gleason''' values as well as the '''Max % Cancer''' and '''Total Cancer Length''' fields. Other fields such as '''Atrophy''', '''Prostatitis''', '''ASAP''', '''PIN''', '''Perineural Invasion''', and '''ECE''' only need to be entered if it was reported. If it was found select ''Yes'' or ''Present'' in the drop down list.<p></p></div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:On the Prostate Biospy sub-form always enter the fields '''# Positive Cores''', '''Total # Cores''', '''# Positive Sites''', and '''Total # Sites'''. If the biopsy has a Gleason Grade, enther the '''Primary''' and '''Secondary Gleason''' values as well as the '''Max % Cancer''' and '''Total Cancer Length''' fields. Other fields such as '''Atrophy''', '''Prostatitis''', '''ASAP''', '''PIN''', '''Perineural Invasion''', and '''ECE''' only need to be entered if it was reported. If it was found select ''Yes'' or ''Present'' in the drop down list.<p></p></div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:Next on Prostate Biopy Cores sub-from enter one row for every site sampled (eg. Right Medial Base). You only need to enter biopsy core details if the report originated at <del class="diffchange diffchange-inline">MSKCC </del>or was reviewed by a <del class="diffchange diffchange-inline">MSKCC </del>pathologist. For the '''# Cores''' field enter the total number of cores taken from that site. The rest of the fields are similair to the above Prostate Biopsy form and can be entered the same way using site specific data.</div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:Next on Prostate Biopy Cores sub-from enter one row for every site sampled (eg. Right Medial Base). You only need to enter biopsy core details if the report originated at <ins class="diffchange diffchange-inline">the hospital </ins>or was reviewed by a <ins class="diffchange diffchange-inline">hospital </ins>pathologist. For the '''# Cores''' field enter the total number of cores taken from that site. The rest of the fields are similair to the above Prostate Biopsy form and can be entered the same way using site specific data.</div></td></tr>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Surveys==</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Surveys==</div></td></tr>
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</table>Robyehttp://caisis.org/wiki/index.php?title=Sample_Prostate_Data_Entry_Guide&diff=1144&oldid=prevRobye: /* Imaging */2009-09-14T17:57:15Z<p><span class="autocomment">Imaging</span></p>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Imaging==</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Imaging==</div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:Under the Diagnostics tab click on Diagnostics. Enter all prostate related scans and any positive chest X-rays. When entering a scan done at <del class="diffchange diffchange-inline">MSKCC </del>copy and paste the impression from the report in CIS into the Notes section. For outside scans available in EMR, type out the impression in the '''Notes''' section. Only enter '''Result''' if the attending physician has interpreted the scan and given a value on either a clinic form or dictation.</div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:Under the Diagnostics tab click on Diagnostics. Enter all prostate related scans and any positive chest X-rays. When entering a scan done at <ins class="diffchange diffchange-inline">the hospital </ins>copy and paste the impression from the report in CIS into the Notes section. For outside scans available in EMR, type out the impression in the '''Notes''' section. Only enter '''Result''' if the attending physician has interpreted the scan and given a value on either a clinic form or dictation.</div></td></tr>
<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:Common tests you will need to enter are CT scans, MRI's, Bone scans, TRUS, and PET scans. You do not need to enter anything in the sub-forms for any scans besides MRI’s and TRUS’s. Always enter '''Data Source''' and '''Data Quality'''.</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>:Common tests you will need to enter are CT scans, MRI's, Bone scans, TRUS, and PET scans. You do not need to enter anything in the sub-forms for any scans besides MRI’s and TRUS’s. Always enter '''Data Source''' and '''Data Quality'''.</div></td></tr>
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</table>Robyehttp://caisis.org/wiki/index.php?title=Sample_Prostate_Data_Entry_Guide&diff=1143&oldid=prevRobye: /* Biochemical Marker / Lab Tests */2009-09-14T17:56:32Z<p><span class="autocomment">Biochemical Marker / Lab Tests</span></p>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Biochemical Marker / Lab Tests==</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Biochemical Marker / Lab Tests==</div></td></tr>
<tr><td class='diff-marker'>-</td><td style="background: #ffa; color:black; font-size: smaller;"><div>:Under the Diagnostics tab click on Lab Tests. All lab tests done at <del class="diffchange diffchange-inline">MSKCC </del>are automatically entered into Caisis. All outside PSA and related lab tests need to be entered from either clinic forms or outside reports in the "OutsideCorres" folder in EMR. Always check EMR if you are unsure whether a lab test is OUT or REV. It will be considered REV if the original outside lab report is in EMR.</div></td><td class='diff-marker'>+</td><td style="background: #cfc; color:black; font-size: smaller;"><div>:Under the Diagnostics tab click on Lab Tests. All lab tests done at <ins class="diffchange diffchange-inline">the hospital </ins>are automatically entered into Caisis. All outside PSA and related lab tests need to be entered from either clinic forms or outside reports in the "OutsideCorres" folder in EMR. Always check EMR if you are unsure whether a lab test is OUT or REV. It will be considered REV if the original outside lab report is in EMR.</div></td></tr>
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<tr><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Imaging==</div></td><td class='diff-marker'> </td><td style="background: #eee; color:black; font-size: smaller;"><div>==Imaging==</div></td></tr>
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</table>Robye