During case abstraction, what is the first step that should be taken?

The first step in case abstraction involves determining the primary site(s) by reading the medical record. This process is fundamental because accurately identifying the primary site lays the groundwork for all subsequent steps in case abstraction. Understanding where the cancer originated allows the registrar to apply the appropriate coding rules and guidelines.

Before delving into the specifics of the site-specific multiple primary rules or equivalent terms and definitions, a clear understanding of the patient’s medical history and diagnosis from the medical record is essential. This step serves as the basis upon which further information, classifications, and analyses are built, ensuring accurate and comprehensive data collection for cancer registry purposes.

While reviewing site-specific multiple primary rules and equivalent terms can be necessary later in the process, they become relevant only after the primary site has been established through the details provided in the medical record. This highlights the importance of starting with direct data gathered from clinical information before moving on to interpretative rules or definitions.