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Instructions and Reporting Requirements Module 8

Instructions and Reporting Requirements Module 8. North Carolina Central Cancer Registry. Electronic Reporting For Facilities March 2013 North Carolina Central Cancer Registry

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Instructions and Reporting Requirements Module 8

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  1. Instructions and • Reporting Requirements • Module 8 North Carolina Central Cancer Registry • Electronic Reporting • For • Facilities March 2013 North Carolina Central Cancer Registry • State Center for Health StatisticsDivision of Public HealthDepartment of Health and Human Services1908 Mail Service CenterRaleigh, NC 27699-1908http://www.schs.state.nc.us/units/ccr/

  2. Part VIII Entering Information Into the New Case Abstract Form

  3. Part VIII: Entering Information Into the New Case Abstract Form • Before beginning a new report, read the following VERY IMPORTANT information • A separate report must be completed and submitted for each independent primary tumor. • Example: If a patient is diagnosed with bladder cancer and a separate kidney cancer, a separate report must be submitted for each diagnosis. • Please complete the New Case Abstract form as ACCURATELY and COMPLETELY as possible. • Once the report is free of errors and is successfully submitted, it is considered as having been reported to the NCCCR.

  4. Part VIII: Entering Information Into the New Case Abstract Form • Before opening a new form and beginning data entry: • Make sure all information necessary for entering the case is available and on hand • Review the chart in its entirety • Make notes on a note pad or scrap paper if necessary to facilitate data entry • Confirm any information that is confusing or unclear with the physician. • Session times out after 30 minutes if no activity takes place. • All information entered for the case (and not submitted) will be lost. • All information necessary for completing the case should be on hand prior to beginning data entry for that case.

  5. Part VIII: Entering Information Into the New Case Abstract Form • There is a Save function • Cases should be saved on a frequent basis. • Once the case is completely entered and all error messages are cleared, hospital staff must select Finish and Complete. . • If it is known that more information is needed or will be forthcoming, hold the case for a later time. • Do not start data entry. • Cases started, but not completed, can be accessed at a later time. • Any information not saved will be lost and must be re-entered.

  6. Part VIII: Entering Information Into the New Case Abstract Form • Treatment information is very important: • Wait to enter report AFTER treatment plan is established • Make sure START DATES for each treatment modality are known • It is not required for all treatment to be completed • Treatment may continue for months or years • For patients who refuse treatment, do not receive treatment for any reason or when there is a decision not to treat (watchful waiting or active surveillance) • Specifically record that decision of why there was not treatment in the treatment text area.

  7. Part VIII: Entering Information Into the New Case Abstract Form • Text is CRITICAL! • Over 100 additional data items will be coded by the NCCCR staff after the report is submitted. • This coding is highly dependent on the text you provide. • Provide as much information and detail as possibleto describe the case. • It is critical to the accuracy and completeness of the final coding for the reported case.

  8. Part VIII: Entering Information Into the New Case Abstract Form • Screen Shots • A screen shot for each tab is provided in the following slides • Each screen shot shows an example of what a completed screen would look like using a hypothetical prostate case • A table per screen shot is included with information on • Each data field on the tab • Any additional coding instructions for each tab • Pay particular attention to the format and content of the text areas used to describe the case • In the screen shots, a red box [] indicates a required field • Text boxes allow a limited number of characters

  9. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.1: Entering Patient Personal Data on the Demographic Tab

  10. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.1: Entering Patient Personal Data on the Demographic Tab- continued

  11. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continued

  12. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab Text describing the primary site and histology (including behavior and grade) MUST be included here to validate the codes selected. Cannot be unknown. Estimate as closely as possible. Pathology information is very important. Be very detailed. Each procedure must include: Date, Procedure, Place, Findings. Use any available text field to provide additional pertinent information.

  13. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continued

  14. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continued

  15. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continued

  16. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.4: Entering Tumor Data on the Dx/Staging Tab - continued

  17. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.4: Entering Tumor Data on the Dx/Staging Tab - continued

  18. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.4: Entering Tumor Data on the Dx/Staging Tab - continued

  19. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.4: Entering Tumor Data on the New Case Abstract Form- continued

  20. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.3: Entering Facility Data on the Hospital Tab Include the NPI number for each facility. Include the NPI number for each physician. Type of facility First date the patient was seen at your facility with cancer. Name and type of Insurance

  21. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.3: Entering Facility Data on the Hospital Tab- continued

  22. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.3: Entering Facility Data on the Hospital Tab - continued

  23. Part VIII: Entering Information Into the New Case Abstract Form Section VIII.2: Entering Facility Data on the Hospital Tab- continued

  24. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.4: Entering Treatment Data on the New Case Abstract Form If the patient did not receive that particular type of treatment, select the flag code of 11. Each procedure must include: Date, Procedure Name and Place (where the procedure was done). Findings, if summarized on the previous tab, do not need to be repeated here.

  25. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.4: Entering Treatment Data on the New Case Abstract Form - continued

  26. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.4: Entering Treatment Data on the New Case Abstract Form - continued

  27. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.4: Entering Treatment Data on the Tumor Data Tab – continued Definition of First Course of Treatment First course of treatment includes all methods of treatment recorded in the treatment plan and administered to the patient at the time of the initial diagnosis and before disease progression or recurrence. A treatment plan describes the type(s) of therapies intended to modify or control the malignancy. The documentation confirming a treatment plan may be found in several different sources; for example, medical or clinic records, consultation reports, and outpatient records. All therapies specified in the physician(s) treatment plan are a part of the first course of treatment if they are actually administered to the patient. An established protocol or accepted management guidelines for the disease can be considered a treatment plan in the absence of other written documentation. If there is no treatment plan, established protocol, or management guidelines, and consultation with a physician advisor is not possible, only record treatment that began within four months of the date of initial diagnosis.

  28. Part VIII: Entering Information Into the New Case Abstract Form • Section VIII.5: Entering Information on the Follow-up Tab – continued Enter the last date the patient was seen or the date of death. Select the option which indicates the condition of the cancer at the time of the visit.

  29. Part VIII: Entering Information Into the New Case Abstract FormSection VIII.5: Entering Information on the Follow-up Tab – continued

  30. Part VIIIEntering Information Into the New Case Abstract FormCompleted

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