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Wiki Laboratory Genetic Oncology Diagnosis Coding - Current vs Present Personal Hx

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cporras20

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If there is a report in the patient's records that indicates there was surgery/removal or cancer/cancerous tumor, can we assume the patient's cancer is now personal history instead of current. Also, does the report need to indicate the patient needs/does not need follow up or radiation/chemotherapy in order for us to assume that the patient is or is not cancer free.
 
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You need to know if there is a plan to treat post surgery. Example: many breast cancers are removed, but radiation, chemotherapy or endocrine therapy will then occur. As long as the cancer is being treated, it is current.
 
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