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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 typeData element
General: demographicsGender
Primary language
Insurance status
General: social characteristicsSmoking status
History of alcohol use
History of other substance abuse
History of homelessness/being marginally housed
History of HIV/AIDS
General: utilizationOtolaryngology-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: outcomesOverall follow-up time
General: resultsImaging 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 planningDate 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
P16 test results*
Treatment plan
Dates of patient outreach
Date of recurrence
 2. In treatmentDate 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