Electronic Reporting for Urology Physician Practices

Instructions and Reporting RequirementsAppendix BElectronic ReportingForDermatology Physician PracticesMarch 2014

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/

North Carolina Central Cancer Registry

Welcome back!

Im Venita Brannigan and I will be your narrator for this training session. The North Carolina Central Cancer Registry has produced this training, along with the previous training, to guide you on how to use the new electronic reporting form for dermatology physician practices.

1Appendix BPhysician Practice Casefinding Tracking Log

You are now entering Training Module: Appendix B which will review a sample Physician Practice Casefinding Tracking Log and the type of information recommended to be included in any log you use as a tool for this process.2Appendix B: Casefinding Tracking LogAppendix B: Physician Practice Casefinding Tracking Log

See the manual for a bigger version of this Physician Practice Casefinding Tracking Log. This is just an example of what a tracking log could look like and what items should be included to help you track the cases you need to report and/or have reported.

In the following three slides we will describe the information you should be including on this and any tracking log.

We have included a PDF version of this log in a separate link on our webpage for you convenience should you wish to use it.

3Appendix B: Casefinding Tracking LogAppendix B: Physician Practice Casefinding Tracking Log

Instructions for completing the Physician Practice Tracking Log General Instructions:Record all cases identified through reports/patient logs included in the casefinding process. This includes reportable and non-reportable cases.If a patient has two or more independent cases of cancer, the patient will need to be entered multiple times, once for each primary.If this tumor for the patient has already been reported, you do not need to enter the information again on the form. You may use the comments section to record additional notes if necessary. You may also update the "Last Date Record Reviewed.Medical Record #If available, enter the patients physician office medical record number.Last NameEnter the patient's last name.First NameEnter the patient's first name.Date of BirthEnter the patient's date of birth.ICD-9-CM CodeIf available, enter the ICD-9-CM code.Type of Cancer/Primary SiteEnter the site (organ, tissue, etc.) of the body where the tumor originated.Date of DiagnosisEnter the date a medical practitioner first stated this patient has a reportable cancer or condition.Date of First VisitEnter the date the patient was first seen at this office with this reportable cancer.

Please turn to Appendix B at the back of the manual where you will find a screen shot of the instructions for using the Physician Practice Tracking Log.

General Instructions:Record all cases identified through reports/patient logs included in the casefinding process. This includes reportable and non-reportable cases.If a patient has two or more independent cases of cancer, the patient will need to be entered multiple times, once for each primary.If this tumor for the patient has already been reported, you do not need to enter the information again on the form. You may use the comments section to record additional notes if necessary. You may also update the "Last Date Record Reviewed."

Medical Record #: If available, enter the patients physician office medical record number.Last Name: Enter the patient's last name.First Name: Enter the patient's first name.Date of Birth: Enter the patient's date of birth.ICD-9-CM Code: If available, enter the ICD-9-CM code.Type of Cancer/Primary Site: Enter the site (organ, tissue, etc.) of the body where the tumor originated.Date of Diagnosis: Enter the date a medical practitioner first stated this patient has a reportable cancer or condition.Date of First Visit: Enter the date the patient was first seen at this office with this reportable cancer.

4Appendix B: Casefinding Tracking LogAppendix B: Physician Practice Casefinding Tracking Log - continued

Instructions for completing the Physician Practice Tracking Log - continuedLast Date Patient Record ReviewedEnter the last date the patient's record was reviewed. This can be extremely helpful in not having to re-review information from previous visits.Date Entered/Submitted to NCCCREnter the date the case report was entered into the physician dermatology report form and therefore submitted to the NCCCR.Leave blank if the case is not reportable.Record Incomplete if a final decision has not been made and further information is needed.

Appendix B Instructions - continued

Last Date Patient Record Reviewed: Enter the last date the patient's record was reviewed. This can be extremely helpful in not having to re-review information from previous visits.

Date Entered/Submitted to NCCCR: Enter the date the case report was entered into the dermatology report form and therefore submitted to the NCCCR.Leave blank if the case is not reportable.Record Incomplete if a final decision has not been made and further information is needed.

5Appendix B: Casefinding Tracking LogAppendix B: Physician Practice Casefinding Tracking Log - continued

Reason not Submitted to NCCCR / CommentsFor cases that were determined not to be reportable, enter the reason the case was not reported to the NCCCR. Examples include: Seen at ____ Hospital. Not a reportable condition PIN III, Case already reported, Waiting on upcoming visit for final diagnosis, etc.Enter additional information here that will assist the reporter in future casefinding efforts. It can be especially helpful to document that a final decision cannot be made. For example, the information in the record was incomplete and additional information from the physician or information from a future visit is needed.Enter the North Carolina hospital name if it is documented that the patient was seen at that North Carolina hospital for the management of this cancer. Leave blank if the patient was not seen at a North Carolina hospital (or it is unknown) for the management of this cancer. This case needs to be reported. Enter the visit date (inpatient or outpatient) at that hospital for the diagnosis or treatment of this cancer. Leave blank if the patient was not seen at a NC hospital (or it is unknown) for the management of this cancer.

Appendix B Instructions - continued

Reason not Submitted to NCCCR / CommentsFor cases that were determined not to be reportable, enter the reason the case was not reported to the NCCCR. Examples include: Seen at ____ Hospital. Not a reportable condition PIN III, Case already reported, Waiting on upcoming visit for final diagnosis, etc.

Enter additional information here that will assist the reporter in future casefinding efforts. It can be especially helpful to document that a final diagnosis cannot be made. For example, the information in the record was incomplete and additional information from a physician or information from a future visit is needed.

Enter the North Carolina hospital name if it is documented that the patient was seen at that North Carolina hospital for the management of this cancer. Leave blank if the patient was not seen at a North Carolina hospital (or it is unknown) for the management of this cancer. This case needs to be reported.

Enter the visit date (inpatient or outpatient) at that hospital for the diagnosis or treatment of this cancer. Leave blank if the patient was not seen at a North Carolina hospital (or it is unknown) for the management of this cancer.

6Appendix BCompleted

This completes the training module for Appendix B which also is the last module for the training on how to use the Electronic Reporting for Dermatology Physician Practices training manual.

Congratulations and thank you! You are welcome to contact us with any questions you may have. Please see the Contacts module on who to contact.

Also, feel free to review all or any segment of this training as often as you wish. It was created to provide a resource for you to use at any time.

Thank you! 7