Operative Standards Medical Record Review Tips

Much of the work related to the CoC’s site visit medical record review is the case selection process. To facilitate an efficient site visit process, please ensure the following when providing the case list to your site reviewer:

• Information is clearly labeled and includes the operative procedure performed at your institution.
• The list includes ALL applicable cases for each standard. If the case is applicable for the standard, it must be included.
  • If your list includes significantly fewer procedures than your analytic caseload for a specific cancer site, please proactively provide an explanation to the site reviewer as to the reasons for the difference in the numbers.
• The list excludes any cases that are not applicable to the standards. For example, the following types of cases must be excluded:
  • Cases that were not treated for curative intent
  • For Standard 5.7: sigmoid, rectosigmoid, or high rectal cases
  • For Standard 5.4: procedures other than axillary lymphadenectomy
  • Cases otherwise ineligible for the standards
• Before the patient list is provided to the site reviewer, it is strongly recommended that it be reviewed to confirm that only applicable cases are included.
  • If the Site Reviewer selects a case not applicable to the standard, there will be one opportunity to swap it for another case. If the second case is still not eligible for the standard, then it will be noted as Not Applicable during the medical record review. Compliance will be calculated based on the total number of applicable records reviewed.
• The list is separated for Standard 5.3: Sentinel Node Biopsy for Breast Cancer and Standard 5.4: Axillary Lymph Node Dissection for Breast Cancer.
  • Targeted axillary node dissection/lymphadenectomy is considered a 5.3 case and not a 5.4 case.

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