Patient Record Abstractor IV’s abstracts and codes medical information from medical records of cancer patients in accordance with guidelines and definitions of the California Cancer Registry (CCR), Surveillance, Epidemiology and End-Results (SEER), California Cancer Surveillance Program (CSP) of Los Angeles County, and the UCLA Cancer Registry, and the Commission on Cancer. ABSTRACTING DUTIES • Abstract clinical and pathological information according to the specific detailed guidelines for each of the agencies named above in the summary statement and assign ICD-0 codes. Enter the information into the computerized Cancer Registry database. • Assign the appropriate accession/sequence number to each reportable case. • Assign the appropriate SEER Summary stage of disease. • Assign the appropriate TNM stage to all analytic cases and Extent of Disease (EOD) • Read and review clinical information and medical record documents in the EMR (CareConnect), and the original paper medical record (when necessary) to obtain and verify the clinical information to abstract into the cancer database. • Abstract treatment information as required to ensure case completion. • Abstract information with a high degree of accuracy (less than 3% error rate as required by the California Cancer Registry. • Meet or exceed productivity standards. CASE FINDING: • Review Dermatology, Pathology, Diagnostic Indexes, autopsy reports, Death Certificates, Bone Marrow and other source documents to determine reportability of cases • Enter reportable identified cases into Cancer Registry suspension file for abstracting with required data elements • Act as resource on abstracting and reportability of cases for other Cancer Data Center staff Fully Remote Schedule: Monday - Friday; 8:00am - 5:00pm (PST) Hourly Salary Range: $38.55 - $50.88
* Experience using CNEXT, EPIC, and MS Office software (Constant) * Experience using computer equipment (Constant) * Experience using internet to locate sites and information needed for cancer reporting (Constant) * CTR certification required * Prefer 5+ years abstracting experience * Must meet productivity standards and State quality standards * Detailed knowledge of the American College of Surgeon standards, California Cancer Registry and SEER standards. * Detailed knowledge of medical terminology, anatomy, pathology, and disease processes. * Detailed knowledge of ICD-0 coding classification scheme * Ability to abstract clinical information from patient records and code data accurately into Cancer Registry database and follow-up if additional information is needed. * Excellent organizational skills in maintaining Cancer Data files. * Skill in prioritizing and performing a variety of duties within a system that has constantly changing priorities, assignments and deadlines. * Detailed knowledge of laws, rules and regulations affecting the confidentiality of medical information. * Skill in working independently and following through on assignments in an environment with frequent interruptions. * Skill in writing legibly and in using basic English words to complete concise documentation. * Knowledge and understanding of functions and activities of various hospital departments contacted for source information to expeditiously coordinate follow up procedures. * Ability to work independently and exercise appropriate decisions in determining follow up actions and complete assignments in a timely manner. * Ability to judge system/procedure malfunction/discrepancies and circumstances to be referred to supervisor for immediate action. * Strong oral and written communication skills for the purposes of conveying information to individuals at various organizational levels and the general public and in completing concise documentation. * Advanced MS Office skills
