Download (Std 5.1) Plan for Non-CTR Staff Central FL Health Alliance

Central Florida Health Alliance – Cancer Registry
Plan for Non-Credentialed Staff to Become Credentialed as Certified Tumor Registrar
Section I: Background Information
Non-Credentialed Staff Name: Joan Smith
Date of Hire for Abstracting: September 15, 2013
Education Level: BA – Communications
Education – Human Anatomy & Physiology: None – Two semesters of Human Anatomy and
Physiology to be successfully completed by July 1, 2014
Work Experience in Cancer Registry: None at time of hire. A minimum of one-year, full-time
work experience (1,950 hours), in the Cancer Registry to be completed by September 15, 2014.
Route for Certified Tumor Registrar (CTR) Certification: Route B; Requires: 1) Minimum
of Associate Degree; 2) Two Semesters of Human Anatomy & Physiology; 3) One Year [1,950
Hours] in Cancer Registry Field – working in or supervising cancer registry that actively
supports cancer registration: collection, management and analysis of cancer incidence data.
Note: According to the NCRA’s Council on Certification, a well-prepared candidate’s
experience should include all basic aspects of a Cancer Registry, including but not limited to:
 Casefinding and Abstracting
 Follow-up
 Cancer Conference
 Cancer Care Committee
 FCDS (Florida Cancer Data System) and NCDB (National Cancer Data Base) submissions
 Reporting
This comprehensive work / experience plan includes the below sections that outline the required
elements by the COC Cancer Program Standards, Standard 5.1, for non-credentialed staff: scope
of supervision, quality control rate with education/training for each of the above topics.
Section
Section II
Section III
Section IV
Section V
Content
Work Experience with Education / Training in the above six major areas of the
Cancer Registry career
Ongoing Education
Other Education Resources
Other Resources
Goal for Certification: Sit for March 2015 examination; eligible for September 2014
examination. Note: Per COC Cancer Program Standard 5.1 (v1.1) …. ”Anyone hired after
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January 1, 2012, to perform abstracting in a COC-accredited program must pass the CTR
examination within three years of the date hired. If the person does not successfully obtain the
CTR credential within the three-year grace period, then he or she may not perform case
abstracting at any COC-accredited program until the credential is obtained.”
Section II: Work Experience with Education and Training
A. CASE FINDING AND ABSTRACTING
Educational Activities
PowerPoint Presentations:
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
N/A
Time
Period
September
2013
Quality
Control
Rate
0%
Moffitt Cancer Center – The
Villages Regional Hospital – 1
Hour
COC Cancer Program Overview –
1.5 Hours
Cancer 101 – 2 Hours
Quality Cancer Data Saves Lives:
The Vital Role of Cancer
Registrars in the Fight Against
Cancer – 2 Hours
Read SEER Self-Instructional Manual
series of books:

Training
Activities
Objectives and Functions of a
Tumor Registry – Book 1
Cancer Characteristics and
Selection of Cases – Book 2
Tumor Registrar Vocabulary: The
Composition of Medical Terms –
Book 3
Human Anatomy as Related to
Tumor Formation – Book 4
Abstracting Medical Record:
Patient Identification, History &
Examinations – Book 5
Read ICD-O (International
Classification of Diseases for
Oncology), pages 1-41:
Review books /
September /
answer questions October
in back of book – 2013
with review by
CTR
0%
Discussion and
review of ICD-O
0%
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September
2013
Review of
Q&A from
Books
Staff
Oversight
Cancer Center
Administrator,
Supervisor or
designated
CTR
Supervisor or
designated
CTR
Supervisor or
designated
CTR
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
Introduction
Differences between ICD-O and
ICD-10
Structure and Format of ICD-O,
Third Edition
Coding Guidelines for Topography
& Morphology
Read AJCC: Cancer Staging Manual,
Seventh Edition, pages 1-15

Review Collaborative Stage Data
Collection System, User
Documentation and Coding
Instructions, General Instructions,
v02.04
Review various abstracting resources:


FORDS (Facility Oncology
Registry Data Standards) by COC
DAM (Data Acquisition Manual)
by FCDS
Multiple Primary & Histology
Rules by SEER / National Cancer
Institute
Introduction to Cancer Registry
software, Electronic Registry System
(ERS)

September /
October
2013
0%
Supervisor or
designated
CTR
Discussion and
review of Cancer
Site-Specific
Staging with
emphasis on
breast, colon,
lung, lymphomas
Discussion and
review of
Collaborative
Staging
September /
October
2013
0%
Supervisor or
designated
CTR
September /
October
2013
0%
Supervisor or
designated
CTR
Discussion and
review of
abstracting
resources
September /
October
2013
0%
Supervisor or
designated
CTR

September
2013
100%
Supervisor or
designated
CTR
General Information on Cancer
Staging and End-Results Reporting
o Purposes & Principles of
Cancer Staging
o Cancer Survival Analysis
Review site-specific staging forms,
AJCC: Cancer Staging Manual,
Seventh Edition

Discussion and
review of Cancer
Staging Manual
Abstract
Observation
and
orientation to
software –
Hands-on
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o Patient Demographics
o Diagnosis
o Staging
o Treatment
o Follow-Up
o User Data
o Site-Specific
o Case Administration
 Suspense
o Case Addition
o Non-Reportable Cases
o Reports
 Follow-Up
o Letter
o Demand
o Lost
o Death List
 Reporting – Brief Overview
 System Administration – Brief
Overview
 System Management – Brief
Overview
 Obtain Log-in ID / Password
Introduction to MOSAIQ Software

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Introduction to HPF (Horizon Patient
Folder) – electronic medical record


with staff
oversight
Successfully
log into
software
Observation
and
orientation to
software –
Hands-on
with staff
oversight
Successfully
log into
software
September
2013
100%
Supervisor or
designated
CTR
Observation
and
orientation to
software –
Hands-on
with staff
oversight
Successfully
log into
September
2013
100%
Supervisor or
designated
CTR
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software
Introduction to LMI (Lake Medical
Imaging) Web Ambassador software

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Introduction to PowerPath software –
pathology reports
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Observation
and
orientation to
software –
Hands-on
with staff
oversight
Successfully
log into
software
September
2013
100%
Supervisor or
designated
CTR
Observation
and
orientation to
software –
Hands-on
with staff
oversight
Successfully
log into
software
September
2013
100%
Supervisor or
designated
CTR

October
Review
2013
FORDS and
DAM with
ERS software
and coding
0%
Supervisor or
designated
CTR
Casefinding

20%

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
October
General
2013
Overview
Review Path
Reports in
HPF Queue
Identify
Cancer Cases
Enter Cancer
Cases into
ERS (Cancer
Registry
Software
Suspense File
Supervisor or
designated
CTR
Discussion regarding TVRH versus
LRMC (Multi-Hospital System)
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Separate Hospital documentation
Same patient – Different Class of
Case
Theory / Importance / Sources
Identify cancer cases with
pathology report review in HPF
Queues
Running “Merge” with ERS
software
Attending morning huddles and
looking up new patients in ERS
software
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Complete FCDS Online Abstracting
Basics Course, which provides
fundamentals of incidence abstracting
and an overview of cancer registration,
focusing on:

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Online training
program
October
2013
0% Certificate
of
Completion
Online Course
with 5 to 20
questions at
end of each
module
Basic abstracting knowledge
General and Florida Rules
Latest Rule Changes
Primary Site, Histology and Grade
Stage at Diagnosis and SiteSpecific Factors
Treatment
Principles of Oncology for Cancer
Registry Professionals – one week
class at AFritz & Associates, LLC

Run Merge in
suspense
(importing
monthly data
file with
identified
cancer
diagnoses,
which is
exported
from STAR
and imported
into ERS
software
(Electronic
Registry
System) –
electronically
generates
suspense files
with first
contact date
(two months
behind)
Five days of classroom and
Training program November
is a concentrated 2013
program
emphasizing
accurate data
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0% Classroom in
Certificate Reno NV
of
Completion
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individualized instruction on basic
registry concepts
o Abstracting
o Staging
o ICD-O coding
o 2007 Multiple Primaries &
Histology Coding Rules
o 2012 Hematopoietic and
Lymphoid Neoplasm Case
Reportability
o Coding Rules Manual
Practical exercises
Extensive training materials
Obtain FCDS Abstractor Code and
access for FCDS IDEA (State Registry
Web Site), which covers six main
areas:
collection
methods.
Take abstractor
November
code examination 2013
on FCDS Web
Site
0%
Certificate
Supervisor or
designated
CTR
Abstracting TVRH Cases
N/A
30%
Supervisor or
designated
CTR
Abstracting TVRH Cases
N/A
20%
Abstracting TVRH Cases
N/A
Supervisor or
designated
CTR
Supervisor or
designated
CTR

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
Basic abstracting knowledge
General and Florida Rules
Latest Rule Changes
Primary Site, Histology and Grade
Stage at Diagnosis and SiteSpecific Factors
Treatment
November
2013 thru
December
2013
January thru
April 2014
May thru
15%
Certification
B. FOLLOW-UP
Educational Activities
Follow-Basic Introduction to Follow-Up
Training
Activities
Explanation of
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Time
Period
Quality
Control
Rate
September 0%
Staff
Oversight
Supervisor
Observe Follow-Up
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Reports – Determining Follow-Up Rates
Reports – Delinquent Lists
Initiating Monthly Follow-Up Lists
Checking Patient Follow-Up with HPF
(electronic medical record, LMI
(radiology) and SSDI (Social Security
Disease Index)
Entering Follow-Up Information from
Lists (HPF, LMI, SSDI) into Cancer
Registry software
Re-generate Monthly Follow-Up Lists
Generate monthly follow-up letters to
doctors, clinics, hospitals, and patients
Follow-Up
Theory and
Process
1) Assist with
checking
patient
follow-up to
HPF, LMI
and SSDI;
2) Enter
information
into ERS
(Cancer
Registry
software)
3) Re-generate
Follow-Up
Lists
2013
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October
2013
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Using
software,
generates
follow-up
letters on to
CFHA
stationery
Facilitates
inserting
letters into
envelopes
with selfaddressed,
stamped
return
envelopes
October
2013
Compare
initial
report to
regenerated
report
October
Retrieve
2013
appropriate
case in ERS
 Enter followup for
patients with
multiple
primaries
 Enter returned
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Entering Follow-Up returned from
letters previously sent for information
Entering recurrence information
appropriately
50%
or
designated
CTR
Supervisor
or
designated
CTR
10%
Supervisor
or
designated
CTR
25%,
decreasing
percentage
until
proficient
Supervisor
or
designated
CTR
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
C. CANCER CONFERENCE
Educational Activities
Training
Activities

Coordinating Tumor Boards – biweekly
meetings (Wednesdays, LRMC-12:30 to
1:30 pm; Thursdays, TVRH-7:00 to 8:00
am)
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
information
Identify a
documented
recurrence
and
appropriately
document it
into ERS
Enter followup data with
appropriate
patient status,
disease status,
F/U source
and
physicians for
follow-up


Review COC Standards applicable to
Cancer Conferences
Documentation for TVRH and LRMC
o Notebooks
o Electronic Files
Meeting Schedule
CME for physicians and CEs for
allied health professionals
Tumor Board Forms
o Checklist
o Case Information
o Sign-In
o Evaluations
o CME and CE Broker
Case Ascertainment / Working with
physicians to get cases
Review of
documentation
Observation of
assigned tasks
Hands-on
experience
with mentoring
of tasks– until
proficient with
independent
work
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Time
Period
November
2013 to
Certification
– Two
Conferences
weekly
(one-LRMC
and oneTVRH)
Quality
Control
Rate
Observation
/ Ongoing
Staff
Oversight
Supervisor
or
designated
CTR

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Agenda
Flyers
Notifying key departments
(pathology, radiology) and physicians
(presenting and case-related)
Ordering slides or films from outside
institutions
Catering Requests
GoToMeeting Overview / Orientation
Tumor Board Set-Up
Moderator(s)
Discussions
Conference Follow-Up /
Documentation
o Documentation for COC
Accreditation
 Grid
 Site
o Patient Name – List
o ERS Abstract / Suspense
o Checklist
o Documentation of CME and
CEs
o ERS
D. CANCER CARE COMMITTEE
Educational Activities
Training
Activities
Coordinating Cancer Care Committee –
Quarterly multidisciplinary meetings
(January, April, July and October –
alternating between LRMC (12:30 to 1:30
pm) and TVRH (7:00 to 8:00 am)

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
Review COC Standards applicable to
Cancer Committee
Policies & Procedures
Documentation for TVRH and LRMC
o Notebooks
o Electronic Files
Meeting Schedule
Agenda



Review of
documentation
Observation of
assigned tasks
Hands-on
experience
with mentoring
of tasks– until
proficient with
independent
work
Page 10 of 16
Time
Period
October
2013 to
Certification
– Quarterly
Meetings
Quality
Control
Rate
Observation
/ Ongoing
Staff
Oversight
Supervisor
or
designated
CTR

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
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Notices for meetings
Preparing notebooks for meetings with
handouts
Attendance, Membership, Chair and
Coordinators
Medical Staff Bylaws
Clinical Liaison Physician
Goals and Cancer Program Plan
Cancer Registry
o Reports
o Quality Management Plan
o Quality Control
 Documentation
 Preparing for physician
reviews
 Case selection
 Printing abstracts
 Reviews
 Follow-Up
documentation
Research
o Working with Nurse
Coordinator
o Determining percentage of
eligible cases registered for
clinical trial by: 1) CFHA
Research Coordinator; 2)
Physician Offices; 3) Moffitt
Cancer Center – Tampa
o Report (compilation and
reporting to committee with
documentation – minutes and
SAR)
Studies
Treatment Assessments
Improvements
Annual Report
Minutes
Radiation Oncology Quality
Physician Credentials / CME
Grand Rounds
o Meeting Schedule
o Coordination of
o Documentation
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CP3R (Cancer Program Practice
Profile Reports) – Breast, Colon and
Rectal Cancers
RQRS (Rapid Quality Reporting
System)
Meeting Follow-up Documentation
o Minutes to Medical Staff
o Handouts in Notebooks
o Attendance
Survey Application Records (SAR)
o Orientation
o Login
E. FCDS SUBMISSIONS
Educational Activities
Training
Activities
Submit personally abstracted cases to FCDS Observation with
through portal (quarterly)
eventual
independent work
to include:




Time
Period
Quarterly,
starting
midDecember
2013
Quality
Control
Rate
100% December
2013,
March 2014
Staff
Oversight
Supervisor
or
designated
CTR
Independent
by June
2014 with
Quality
Reports
from FCDS
provided to
mentor
and/or
supervisor
following
each
submission
case selection
for reporting
to FCDS
Uploading
selected cases
on to FCDS
Web site
Edits / Forced
cases /
Follow-Up
Quality
Reviews &
Follow-Up
F. NCDB SUBMISSIONS
Educational Activities
Training
Activities
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Time
Period
Quality
Control
Rate
Staff
Oversight
Assist supervisor with NCDB Submissions Observation of case
(annual)
selection,
processing
GenEdits, data
edits (limited
participation with
edits), data
submission and
follow-up reports
Conduct NCDB Submissions (annual)
Independently
select cases,
process GenEdits,
complete data edits,
submit data on
NCDB Web site
and receive NCDB
follow-up report
January
2014
100%
Reports
with
GenEdits /
NCDB
January
2015
0%
Reports
with
GenEdits /
NCDB
with
observation
by Director
and
Supervisor
Supervisor
or
designated
CTR
Supervisor
or
designated
CTR
G. REPORTING – GENERAL
Educational Activities
Training
Activities
Introduction of Reporting
o Significance of reporting
o Report requests
o Person(s) requesting report
o Purpose of report request
o Parameter(s) / Criteria (data to be
included)
o Information needed / type of
report
o Patient name / identifiers
o Incidence
o Report – approval to prepare and
disseminate
o Case selection
o Report types / presentation
o List
o Table
o Cross-Tab
Time
Period
o Discussion of March
reporting
2014
o Teaching ERS
Report
System
o Hands-on
experience
with reports
o Observation
of report
generation
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Quality
Control
Rate
100%
decreasing
as
experience
increases.
Reviews
of report
requests
and
generated
reports.
Staff
Oversight
Supervisor
or
designated
CTR
o Graph
o Survival
o Data analysis, cleanup (understanding
and verifying the data for validity)
o Documentation / Request Log
Section III: Ongoing Education

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
Florida Cancer Data System (FCDS) Webcast Series – 3rd Thursday, 1:00 – 3:00 pm
FCDS Sponsored / NAACCR Cancer Registry & Surveillance Webinar Series that focus on
site-specific cancers and abstracting – Shands Medical Center – Gainesville – Monthly
Webinar education programs
National Cancer Registrars Association (NCRA) Annual Conference – three day conference,
May 2014 (Note: Annual conference alternates by region, eastern, western and Midwestern.)
Florida Cancer Registrars Association (FCRA) Annual Conference – July 2014, Orlando FL,
two day conference
FCDS Annual Conference – July 2014, Orlando FL, two-day conference (following FCRA
Annual Conference)
Consider CTR Exam Course (date and location to be determined)
Section IV: Other Education Resources
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Cancer Registry Management: Principles and Practices for Hospitals and Central
Registries, Edition 3, Copyright 2011, Author: National Cancer Registrars Association,
ISBN: 978-0-7575-6900-5, Kendall Hunt Publishing (Phone: 800-228-0810)
National Cancer Registrars Association (NCRA) Membership – https://www.ncra-usa.org/
o Connection (newsletter)
o Journal of Registry Management (peer-reviewed journal)
o Newsblasts
o Education Resources - http://www.cancerregistryeducation.org/
NCRA Education Foundation – http://www.ncraeducationfoundation.org/index.html
NCRA Council on Certification – http://www.ctrexam.org/about/index.htm
Commission on Cancer Web site – http://www.facs.org/cancer
o The COC Source (monthly newsletter)
o The COC Brief (weekly news brief e-mail)
Florida Cancer Registrars Association (FCRA) Membership - https://www.fcra.org/
o SunTimes (newsletter)
o Newsblasts
Florida Cancer Data System (FCDS) - http://fcds.med.miami.edu/
o Monthly Memo – http://www.fcds.med.miami.edu/inc/newsletters.shtml - FCDS
monthly memo written especially for registrars (used as a source for updates or
replacement pages to manuals)
o Register (Quarterly Newsletter) –
http://www.fcds.med.miami.edu/inc/newsletters.shtml
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o
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
Florida Cancer Data System (FCDS) Education & Training On-Line Abstractor
Training Course – http://www.fcds.med.miami.edu/inc/training.shtml online
abstractor training course
National Cancer Institute (NCI) Web Site http://www.cancer.gov
o General Information regarding Cancer
o SEER Self-Instructional Manuals for Tumor Registrars –
http://seer.cancer.gov/training/manuals/
o SEER (Surveillance Epidemiology and End Results) – Right Tab – Information for
Cancer Registrars http://seer.cancer.gov/registrars/
COC / AJCC Online Education – http://www.eo2.commpartners.com/users/acs - on-demand
Webinars, Clinical Liaison Physician (CLP) Education
Brain Tumor Registry Reporting Training Materials –
http://www.cdc.gov/cancer/npcr/training - This includes a PowerPoint presentation on benign
brain and CNS Tumors along with speaker notes. It also has exercises with answers provided.
Section V: Other Resources

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
Commission on Cancer, Cancer Program Standards 2012: Ensuring Patient-Centered Care –
http://www.facs.org/cancer/coc/programstandards2012.pdf
2012 Florida Cancer Data System (FCDS) Data Acquisition Manual (DAM) –
http://www.fcds.med.miami.edu/inc/DAM.shtml
- details cancer data reporting guidelines and casefinding mechanisms for identifying
reportable cancers
2012 COC FORDS Manual (Facility Oncology Data Standards) –
http://www.facs.org/cancer/coc/fords/fords-manual-2013.pdf - data standards for COC
approved cancer programs (Note: FORDs errata is issued quarterly and posted on the COC
Web site)
SEER Program Coding and Staging Manual 2012 –
http://seer.cancer.gov/tools/codingmanuals/ - The 2012 Surveillance, Epidemiology and End
Results (SEER) Program Coding and Staging Manual is effective for cases diagnosed
January 1, 2012, and forward. Previous edition of this manual are available on the SEER
Web site.
2007 MPH Rules – Solid Tumors, rev August 24, 2012 –
http://www.seer.cancer.gov/tools/mphrules/index.html - On the home page, click on
“Information for Cancer Registrars” – MP/H Rules
2012 MPH Rules – Heme/Lymph Neoplasms and Interactive Heme/Lymph Database –
http://seer.cancer.gov/seertools/hemelymph/ - On the home page, click on “information for
Cancer Registrars,” Hematopoietic & Lymphoid Neoplasm Project
Collaborative Stage, Version 02.04 – http://web2.facs.org/cstage0204/schemalist.html - The
Collaborative Stage (CS) schema listing for this version is also available
ICD-O-3 Coding Materials – http://www.seer.cancer.gov/icd-o-3/index.html - On the home
page, click “Data Collection Tools,” Errata and Clarifications.”
Collaborative Stage Data Collection System – http://www.cancerstaging.org/cstage - On the
home page, click “news” to see if there are updates.
Page 15 of 16
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

SEER *RX – Interactive Drug Database – http://seer.cancer.gov/seertools/seerrx/ - a one-step
lookup for coding oncology drug and regimen treatment categories in cancer registries
AJCC Staging Manual, 7th Edition (plus errata) – http://www.springer.com/medicine Springer (publisher) ISBN 978-0-387-88440-0
Electronic Registry System Manual / Multi-Hospital (for software) – http://www.erscan.com/files/manual/mh/ers-mh.pdf
References:
1) COC Cancer Program Standards, v1.1
2) FCDS Web Site – Education & Training
3) NCRA Web Site – Education
4) NCI and SEER Web Sites
5) NCRA Council on Certification Web site
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