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Table 1 Data elements collected in chart review

From: Customized registry tool for tracking adherence to clinical guidelines for head and neck cancers: protocol for a pilot study

Phase/data type

Data element

General: demographics

Gender

Race/ethnicity

Primary language

Insurance status

General: social characteristics

Smoking status

History of alcohol use

History of other substance abuse

History of homelessness/being marginally housed

Comorbidities

History of HIV/AIDS

General: utilization

Otolaryngology-Head and Neck Surgery visit dates and status (attended/canceled/no-show/scheduled)

Medical oncology visit dates and status (attended/canceled/no-show/scheduled)

Radiation oncology visit dates and status (attended/canceled/no-show/scheduled)

Patient only seen for hospitalization

Most recent visit date

General: outcomes

Overall follow-up time

Survival

General: results

Imaging for cancer monitoring

All imaging

Thyroid-stimulating hormone test dates and results

All lab test dates and results

Pathology dates and results

 1. Workup and treatment planning

Date of diagnosis

Date of referral to tumor board

Date of presentation at tumor board

Date imaging appointments sent, scheduled, and completed

Date referrals sent, scheduled, and completed

TNM staging

Site

Histology

P16 test results*

Treatment plan

Dates of patient outreach

Date of recurrence

 2. In treatment

Date of dental evaluation

Date of treatment start

Date of treatment completion

Recommended and received dose and treatment sessions

Treatment result (e.g., completed, not completed, delays)

Dates of treatment delays/complications

Type of treatment delays/complications

Dates post-treatment imaging ordered and completed

Dates of patient outreach

  1. *P16 immunohistochemistry tests are recommended for newly diagnosed oropharyngeal squamous cell carcinomas
  2. Supplemental data collected from health IT tool to describe implementation of the tool, all other data collected from chart review