Electronic Reporting for Urology Physician Practices

Instructions and Reporting RequirementsModule 7Electronic ReportingForFacilitiesMarch 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 Ashanti Scott-Prince and I will be your narrator for this training session. The North Carolina Central Cancer Registry has produced this training, along with the previous trainings, to guide you on how to use the New Case Abstract form for facilities.

1Part VII General Notes for Using the New Case Abstract Form

You are now entering Training Module 7 which will review Part VII: General Notes for Using the New Case Abstract Form as identified in the Electronic Reporting for Facilities training manual.

As noted in Module 1, the North Carolina Central Cancer Registry (NCCCR) collects, processes, and analyzes data on all cancer cases diagnosed among North Carolina residents. This is primarily a cancer surveillance activity, monitoring the incidence of cancer among the various populations of the state.All health care providers are required by law to report cases to the NCCCR (as in nearly all other states). Traditional data collection for central cancer registries has been primarily from hospitals. As medical advances have occurred, diagnosis and treatment of certain cancers has moved from the acute care setting to being fully cared for within the physician/clinic office and, therefore, never received and counted. Examples include melanoma of the skin; prostate cancer; and many hematopoietic malignancies like chronic lymphocytic leukemia, polycythemia vera and myelodysplastic syndrome. The NCCCR supplements hospital data with reports from physician/clinic offices who diagnose cases that are not seen in a hospital. In addition, death certificates and pathology laboratory reports are used to help identify cases that are missed in this routine reporting by hospitals and physician/clinic offices. As duplicate reports are consolidated in the data editing process, the purpose of this concerted effort is to alleviate under-reporting or a delay in reporting which can adversely affect incidence rates and research from incomplete data collection.

Please ensure you have your Electronic Reporting for Facilities training manual open to follow along (or printed out to use for note taking).We will now resume the training.

2Part VII: General Notes for Using the New Case Abstract FormSection VII.1: Orientation to the Data Entry ScreensThe size of the screen can be adjusted to fit the monitor by holding down the key and pressing to expand the display or pressing to shrink the display.For all consistency and ease in typing, set the to on.Entering all information in ALL CAPS is preferred.

Part VII: General Notes for Using the New Case Abstract Form begins with Section VII.1: Orientation to the Daily Entry Screens. Please remember to follow along in the manual.

First, let me pass on a couple of tips to you before we look at the screen shot of the reporting screen which is shown on the next slide:

The size of the screen can be adjusted to fit your monitor by holding down the key and pressing the plus key to expand the display or pressing minus key to shrink the display.

For consistency and ease in typing, set the to on. Entering all information in ALL CAPS is preferred.

3Part VII: General Notes for Using the New Case Abstract FormSection VII.1: Orientation to the Data Entry Screens

Patient Name (after it is entered) and Abstractor initials will display at the top of each page. Fields are dispersed onto four tabs.Several fields are pre-assigned a default value. This can and should be changed if a different value applies.There are 1 submit option.This triangle indicates a drop down menu is available. The value in the field must be one of these menu options.Non hospital facilities must select save when a case is complete.

Now we come to the screen shot of the reporting form which can also be seen in the manual.

Please view the yellow caption boxes (described below) for pertinent fields on this screen.

At the top of the screen is the field called Name. You will begin the report with this field. After the patients name is entered, the Patient Name and Abstractor initials will display at the top of each page.

Moving down the screen one line, you will find the two buttons named Save and Finish and Complete. The two buttons are important and we will discuss in more detail later.

On the next line you will see four tabs. The fields for data entry are categorized and dispersed onto the screens these four tabs open. They are: Demographic, DX/Staging, Hospital and Follow-up. You will select each one to enter the data needed in each category.

A triangle next to a field indicates a drop down menu is available. The value in the field must be one of the options that is shown on the drop down menu.

Several fields are pre-assigned a default value. This can and should be changed if a different value applies.

4Part VII: General Notes for Using the New Case Abstract FormSection VII.2: General Instructions for Using the Data Entry ScreensDefaulted ValuesWhen a user opens a New Case Abstract, several fields are automatically assigned a default value. Default values can and should be changed if a more appropriate value applies.Moving from Field to FieldThe key or the mouse can be used to advance between fields.The key can be used but will not advance to the next field while in a text box.Required FieldsFields marked with a red box ( ) may not be left blank.Any required fields left blank will receive an error message on submit.

We now move to Section VII.2: General Instruction for Using the Data Entry Screens.

You can flip between this slide and the previous slide or just use the screen shot in the manual as you follow along.

There are certain Defaulted Values built into the screen. This means, when you open a New Case Abstract, several fields are automatically assigned a default value. These can and should be changed if a more appropriate value applies.To simplify your ability for Moving from Field to Field, the key on your computer or your mouse can be used to advance between fields. The key can be used but will not advance to the next field while in a text box.

There are definite Required Fields. These fields are marked with a red box following the field label and may not be left blank. Any required fields left blank will receive an error message on submission. Hospitals will be required to enter additional fields and must contact their assigned Field Services Representative for additional information. 5Part VII: General Notes for Using the New Case Abstract FormSection VII.2: General Instructions for Using the Data Entry ScreensSelection (Drop Down) MenusSelection menus are provided for data fields that are limited to a defined set of codes.For fields that provide a selection menu, the value in the field must be one of the menu box options.Entering free text is not allowed. To open the selection menu, click on the triangle beside the data field.

Regarding the Selection (Drop Down) Menus, selection menus are provided for data fields that are limited to a defined set of codes.

For fields that provide a selection menu, the value in the field must be one of the menu box options.

Entering free text is not allowed.

To open the selection menu, click on the triangle beside the data field.

6Part VII: General Notes for Using the New Case Abstract FormSection VII.2: General Instructions for Using the Data Entry ScreensSelection (Drop Down) Menus - continuedThere are two main types of selection menus.For the first type of selection menu, the user may:Search for a menu option by entering letters or numbers of the search criteria in the Search box.The system highlights the options as the entry is typed.Keep typing to continue drilling down to a more specific option.Click or use the mouse, to select the option and Close the menu.Scroll through the options using the scroll bar on right side of box.Highlight the menu option by clicking on the desired selection.

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There are two main types of selection menus. See the screen shot here or in the manual. The yellow caption boxes again are used to identify the location for each of these steps we discuss here.

For the first type of selection menu, the user may:

Search for a menu option by entering letters or numbers of the search criteria in the Search box. The system highlights the options as the entry is typed. Keep typing to continue drilling down to a more specific option. Click or use the mouse, to select the option and Close the menu.OR

Scroll through the options using the scroll bar on right side of box. Highlight the menu option by clicking on the desired selection7Part VII: General Notes for Using the New Case Abstract FormSection VII.2: General Instructions for Using the Data Entry ScreensSelection (Drop Down) Menus - continuedThere are two main types of selection menus. continuedFor the first type of selection menu continuedOnce the desired selection is highlighted:Click Close to update the field with the selection.Note: for the Date Flag fields, click Update to update the field.Once a selection is made, the user cannot type in the field but can make another selection from the drop down menu.

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Next, see caption box number three.

Once the desired selection is highlighted, click Close to update the field with the selection.

Note: For the Date Flag fields, click Update to update the field.

Once a selection is made, the user cannot type in the field but can make another selection from the drop down menu.

8Part VII: General Notes for Using the New Case Abstract FormSection VII.2: General Instructions for Using the Data Entry ScreensSelection (Drop Down) Menus - continuedThere are two main types of selection menus continuedFor the second type of selection menuthe user may simply select an option by clicking on the menu option. The menu box will close when the selection is made.

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See caption box #4.

For the second type of selection menu, the user may simply select an option by clicking on the menu option as shown here for the Sex/Gender menu.

The menu box will close when the selection is made.

9Part VII: General Notes for Using the New Case Abstract FormSection VII.2: General Instructions for Using the Data Entry ScreensText BoxesText is criticalMost information being entered will be in the form of text.Some text boxes are a single row and are designated to capture specific information, such as Last Name.Some text boxes have multiple rows and allow free form text to describe the facts about the case.Refer to the specific data fields in Part VIII for a description of the requirements for each designated text box.Helpful tips for using text boxes:Copy and paste from electronic medical reports is not allowed in text boxes

Now a discussion about Text Boxes.

Text is critical. I cant emphasize this enough so I will repeat it ... Text is critical.

Most of the information being entered will be in the form of text.

Some text boxes are a single row and are designated to capture specific information, such as Last Name.

Some text boxes have multiple rows and allow free form text to describe the facts about the case.

Refer to the specific data fields in Part VIII for a description of the requirements for each designated text box.I will begin here, and continue on the next slide, with a few helpful tips for using the text boxes:

Copy and paste from electronic medical reports is not allowed in text boxes.

10Part VII: General Notes for Using the New Case Abstract FormSection VII.2: General Instructions for Using the Data Entry ScreensText Boxes - continuedHelpful tips for using text boxes:Copy and paste from electronic medical reports is not allowed in text boxesThe number of characters allowed for each text box varies according to the requirements for the data item.Do not use the key within a text area to go to the next line.This interferes with data transmission conducted later by NCCCR staff.Instead, use periods to separate sentences and paragraphs.Use the key or the mouse to move to the next field.

Continuing with helpful tips for entering text, keep in mind:

The number of characters allowed for each text box varies according to the requirements for the data item.

Do not use the key within a text area to go to the next line as this interferes with data transmission conducted later by NCCCR staff. Instead, use periods to separate sentences and paragraphs.

Use the key or the mouse to move to the next field.

11Part VII: General Notes for Using the New Case Abstract FormSection VII.2: General Instructions for Using the Data Entry ScreensDate FieldsDates are entered in month, day and year (MMDDYYY) format.Slashes between month, day and year numbers can be entered but are not required.Unknowns should be avoidedIf an exact date is unknown, try to estimate as closely as possible, even if it is only the year.An attempt to estimate at least the year should be done.A reasonable estimate is better than unknown.Eureka will accept partial dates. Record as much as can be determined using the following as a guideline:If the complete date is known or can be estimated, enter the full eight-digit date; for example, 08012012If only the month and year are known or can be estimated, enter the six-digit date for the month and year only; for example, 082012If only the year is known or can be estimated, enter the four-digit year; for example, 2012.

Date Fields have specific guidelines as well.

Dates are entered in month, day and year (MMDDYYYY) format. Slashes between month, day and year numbers can be entered but are not required.Unknowns should be avoided. If an exact date is unknown, try to estimate as closely as possible, even if it is only the year. An attempt to estimate at least the year should be done. A reasonable estimate is better than unknown. Eureka will accept partial dates. Record as much as can be determined using the following as a guide:If the complete date is known or can be estimated, enter the full eight-digit date; for example, 08012012.If only the month and year are known or can be estimated, enter the six-digit date for the month and year only; for example, 082012.If only the year is known or can be estimated, enter the four-digit year; for example, 2012.

12Part VII: General Notes for Using the New Case Abstract FormSection VII.2: General Instructions for Using the Data Entry ScreensDate FieldsDate fields may only be used to specify a complete or partial valid date (one that can be referenced on a calendar).In situations where a valid date is unknown or not applicable, the date field is to be left blank.The date field may be left blank only under the following conditions:None of the date information can be determined or estimated. The month, day and year are unknown.The date is not applicable.For example, the patient did not receive radiation therapy, therefore, a radiation therapy start date is not applicable.

Date fields may only be used to specify a complete or partial valid date (one that can be referenced on a calendar).

In situations where a valid date is unknown or not applicable, the date field is to be left blank.

However, the date field may be left blank only under the following conditions:None of the date information can be determined or estimated. The month, day and year are unknown.The date is not applicable. For example, the patient did not receive radiation therapy, therefore, a radiation therapy start date is not applicable.

13Part VII: General Notes for Using the New Case Abstract FormSection VII.2: General Instructions for Using the Data Entry ScreensDate Flag FieldsFor certain date fields, a special date flag field has been provided to explain why the date field was left blank.If the date field is being left blank, and that date field has an associated date flag, a date flag code must be selected to indicate why the date is unknown or not applicable.A Date and a Date Flag cannot both be entered.They are mutually exclusive where only one or the other can be used.Entering one will set the other to blank.If a date is applicable, the flag field will be set to blank automatically.

In addition to Date Fields, you will find Date Flag Fields. These were created for certain date fields to provide an explanation of why the date field was left blank.

If the date field is being left blank, and that date field has an associated date flag, a date flag code must be selected to indicate why the date is unknown or not applicable. A Date and a Date Flag cannot both be entered. They are mutually exclusive where only one or the other can be used.

Entering one will set the other to blank. If a date is applicable, the flag field will be set to blank automatically.

14Part VII: General Notes for Using the New Case Abstract FormSection VII.2: General Instructions for Using the Data Entry ScreensDate Flag Fields - continuedTo select the date flag code, open the selection menu, click on the appropriate code and then click [Update]. The [Close] button merely closes the box and does not enter the selection for the date flag.

To select the date flag code, open the selection menu, click on the appropriate code and then click the [Update] button.

It is important to note that the [Close] button merely closes the box and does not enter the selection for the date flag. So, if you have made a selection, please be sure you click the [Update] button instead to ensure your selection is entered.

Again, you can find the screen shot shown here and view of the menu for selecting a date flag in the manual.

15Part VII: General Notes for Using the New Case Abstract FormSection VII.2: General Instructions for Using the Data Entry ScreensDate Flag Fields - continuedThe table below describes when each date flag code should be used. Remember that a flag code is only assigned when the associated date field is being left blank.

CodeWhen to UseDate Entered/Not ExpectedThis is used by the system to indicate that the flag is being left blank. In this situation, there must be a complete or partial valid date in the associated date field.Code 10Use this code if it is unknown if this event occurred. In this situation, the event would be indicated or suspected but confirmation that the event took place could not be confirmed. For example, the patient was referred for a radiation therapy consult but it is unknown if treatment was recommended.Code 11 (most commonly used code)Use this code when it is known that the event did not occur. Therefore, a valid date is not applicable. Code 12 (avoid unknown, estimate if possible)Use this code when it is known that the event occurred but a valid date (complete or partial) is not known and could not be estimated. In this situation, the date is entirely unknown. This should be avoided. Estimating is preferred over coding unknown.Code 15 (try to wait until the date is known)Use this code when it is expected that the event will occur in the future but has not yet occurred. For example, it is known that radiation therapy was recommended but the treatment had not started at the time of entering the case. Note: It is preferred that the user wait to enter the case until the start date is known. If that is not possible, then use code 15. Be sure that these cases are kept in a special location so that they can be followed up on later and can be entered when the treatment start date is known.

Remember that a flag code is only assigned when the associated date field is being left blank.

The table shown here describes when each date flag code should be used. This information can also be found in the manual.

Date Entered/Not ExpectedThis is used by the system to indicate that the flag is being left blank. In this situation, there must be a complete or partial valid date in the associated date field.

Code 10Use this code if it is unknown if this event occurred. In this situation, the event would be indicated or suspected but confirmation that the event took place could not be confirmed. For example, the patient was referred for a radiation therapy consult but it is unknown if treatment was recommended.

Code 11 (most commonly used code)Use this code when it is known that the event did not occur. Therefore, a valid date is not applicable.

Code 12 (avoid unknown, estimate if possible)Use this code when it is known that the event occurred but a valid date (complete or partial) is not known and could not be estimated. In this situation, the date is entirely unknown. This should be avoided. Estimating is preferred over coding unknown.

Code 15 (try to wait until the date is known)Use this code when it is expected that the event will occur in the future but has not yet occurred. For example, it is known that radiation therapy was recommended but the treatment had not started at the time of entering the case.

Note: It is preferred that the user wait to enter the case until the start date is known. If that is not possible, then use code 15. Be sure that these cases are kept in a special location so that they can be followed up on later and can be entered when the treatment start date is known.

16Part VIIAccessing the Eureka New Case Abstract FormCompleted

This completes the training module for Part VII: General Notes for Using the New Case Abstract Form. Please close when you are ready and move to the next link to access the training module for Part VIII: Entering Information Into the New Case Abstract Form in the Electronic Reporting for Facilities training manual.

Thank you! 17