Our facilities are trying to determine the best methods for
monitoring CAP Cancer Protocol compliance and are seeking ideas from
other registrars.

Are the pathology reports being monitored by the registrar or
pathology personnel to insure required data elements are
documented?

If the paths are missing required elements, are they being amended
or re-dictated to include those missing elements?

Are the pathologists using the checklists as they are listed on the
CAP website or are the path reports in a text summary under the
final diagnosis or comment section?

If the checklists are not being utilized, are the people performing
QA on the paths searching through the path report to see if all
required elements are documented somewhere in the report or would
the path report be considered non-compliant with the protocols if
not easily identified?

Thank you in advance for sharing your information. I think that
this is an issue that other registrars would benefit from input for
across the nation.

Charla Carter, CTR
Cincinnati, Ohio