Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 4 - DEPARTMENT OF HEALTH SERVICES - NONCOMMUNICABLE DISEASES
Article 4 - CANCER REGISTRY
Section R9-4-403 - Case Reports
Universal Citation: AZ Admin Code R 9-4-403
Current through Register Vol. 30, No. 38, September 20, 2024
A. A physician, doctor of naturopathic medicine, dentist, registered nurse practitioner, or the designee of a clinic shall:
1. Prepare a case report in a format provided
by the Department;
2. Include the
following information in the case report:
a.
The name, address, and telephone number of, or the identification number
assigned by the Department to, the reporting facility;
b. The patient's name, and, if applicable,
the patient's maiden name and any other name by which the patient is
known;
c. The patient's address at
the date of last contact, and address at diagnosis of cancer;
d. The patient's date of birth, Social
Security number, sex, race, and ethnicity;
e. The date of first contact with the patient
for the cancer being reported, as applicable;
f. If the patient is an adult, the:
i. Primary type of activity carried out by
the business where the patient was employed for the most number of years of the
patient's life before the diagnosis of cancer, and
ii. Kind of work performed by the patient for
the most number of years of the patient's life during which the patient was
employed for a salary or wages before the diagnosis of cancer;
g. The patient's medical record
number, if applicable;
h. The date
of diagnosis of the cancer being reported;
i. If the diagnosis was not made at the
reporting facility, the name and address of the facility at which the diagnosis
was made;
j. The primary site and
the specific subsite area within the primary site for the cancer being
reported;
k. The following
characteristics of the tumor at diagnosis:
i.
Size;
ii. Histology, the
microscopic structure of the tumor cells and surrounding tissues in relation to
their function;
iii. Grade, the
degree of resemblance of the tumor to normal tissue, as an indication of the
severity of the cancer; and
iv.
Laterality, the side of a paired organ or the side of the body in which the
primary site of the tumor is located;
l. A code that describes the presence or
absence of malignancy in a tumor;
m. Whether the cancer had spread from the
primary site at the time of diagnosis and, if so, to where;
n. The extent to which the cancer has spread
from the primary site;
o. A
narrative description of the extent to which the cancer had spread at
diagnosis, as applicable;
p. The
method or methods by which the diagnosis was made, or whether the method by
which the diagnosis was made is unknown;
q. Whether the patient's laboratory results
show the presence of specific substances, derived from tumor tissue, whose
detection in the blood, urine, or tissues of a human body indicates the
presence of a specific type of tumor, if applicable;
r. Any other physiological symptoms or
diagnostic criteria that may indicate the presence of a specific type of tumor,
if applicable;
s. For each treatment the patient received, the type
of treatment, date of treatment, and the name of the facility where the
treatment was performed;
t. Whether any residual
tumor cells were left at the edges of a surgical site, after surgery to remove
a tumor at the primary site;
u. Whether the patient
is alive or dead, including:
i. The date of
last contact if the patient is alive, and
ii. The date of death if the patient is
dead;
v. Whether or not the patient has evidence of a
current cancer, carcinoma in situ, or benign tumor of the central nervous
system as of the date of last contact or death, or whether this information is
unknown;
w. The name of the physician, nurse practitioner, or
doctor of naturopathic medicine providing medical services to the patient;
and
x.
Whether the patient has a history of other cancers, and if so, identification
of the primary site and the date the other cancer was diagnosed; and
3. Use codes and a coding format
supplied by the Department for data items specified in subsection (A)(2) that
require codes on the case report.
B. The cancer registry of a hospital that reports as specified in R9-4-404(A) shall:
1. Prepare a case report in a format
provided by the Department;
2.
Include the information specified in subsection (A) and the following
information in the case report:
a. The
patient's unique accession number, separate from a medical record number, that
was assigned by the hospital's cancer registry to the patient for
identification purposes;
b. The
unique sequence number assigned by the cancer registry to the specific cancer
within the body of the patient being reported;
c. The date the patient was admitted to the
hospital for diagnostic evaluation, cancer-directed treatment, or evidence of
cancer, carcinoma in situ, or a benign tumor of the central nervous system, if
applicable;
d. The date the patient
was discharged from the hospital after the patient received diagnostic
evaluation or treatment at the hospital, if applicable;
e. The source of payment for diagnosis or
treatment of cancer, or both;
f.
The level of the facility's involvement in the diagnosis or treatment, or both,
of the patient for cancer;
g. The
year in which the hospital first provided diagnosis or treatment to the patient
for the cancer being reported;
h.
The patient's county of residence at diagnosis of cancer;
i. The patient's marital status and age at
diagnosis of cancer, place of birth, and, if applicable, name of the patient's
spouse;
j. If the patient is under
18 years of age and unmarried, the name of the patient's parent or legal
guardian;
k. A narrative description of how the
cancer was diagnosed, including a description of the primary site and the
microscopic structure of the tumor cells and surrounding tissues;
l. The
number of regional lymph nodes examined and the number in which evidence of
cancer was detected;
m. The clinical, pathological, or other staging
classification, based on the analysis of tumor, lymph node, and metastasis;
n. The patient's clinical, pathological, or other
stage group;
o. If the cancer was diagnosed before 2018, the code
for the person who determined the stage group of the patient;
p. A
narrative description of the clinical evaluation of x-ray diagnostic films and
scans of the patient, and the dates of the films or scans;
q. A
narrative description of laboratory tests performed for the patient, including
the date, type, and results of any of the patient's laboratory tests;
r. A narrative description of the results of the
patient's clinical evaluation;
s. The procedures used
by the reporting facility to obtain a diagnosis and staging classification,
including:
i. The dates on which the
procedures were performed ; and
ii.
The name of the facilities where the procedures were performed, if different
from the reporting facility;
t. A narrative description of any cancer-related
surgery on the patient, including the:
i. Date
of surgery ;
ii. Name of the
facility where the surgery was performed, if different from the reporting
facility ; and
iii. Type of
surgery;
u. The code associated with the type of surgery
performed on the patient and the date of surgery;
v. The codes associated
with the:
i. Extent of lymph node surgery;
ii.
Number of lymph nodes removed;
iii. Surgery of
regional sites, distant sites, or distant lymph nodes; and
iv.
Reason for no surgery or that surgery was performed;
w.
Whether reconstructive surgery on the patient was performed as a first course
of treatment, delayed, or not performed;
x. A narrative
description of cancer-related radiation treatment administered to the patient,
including the:
i. Date of radiation treatment
;
ii. Name of the facility where
the radiation treatment was performed, if different from the reporting facility
; and
iii. Type of radiation;
y. As applicable, the
code specifying that radiation treatment was administered or associated with
the reason for no radiation treatment;
z. The code associated
with the type of radiation treatment administered to the patient and the date
of radiation treatment;
aa. A narrative
description of cancer-related chemotherapy administered to the patient,
including the:
i. Date of cancer-related
chemotherapy ;
ii. Name of the
facility that administered the chemotherapy, if different from the reporting
facility ; and
iii. Type of
chemotherapy;
bb. The code
associated with the type of chemotherapy administered to the patient and the
date of chemotherapy;
cc.
The code associated with any other types of cancer- or non-cancer-directed
first course of treatment, not otherwise coded on the case report for the
patient, including:
i. Hormone therapy,
immunotherapy, hematologic transplant, or endocrine procedures administered to
the patient;
ii. Additional
surgery, radiation, or chemotherapy administered to the patient; or
iii. Other treatment administered to the
patient;
dd. If applicable, a narrative description of any
other types of cancer or non-cancer-directed first course of treatment,
including:
i. The dates of the treatment;
ii.
The names of the facilities where the treatment was performed, if different
from the reporting facility; and
iii. The type of
treatment;
ee. If the patient's treatment included both
surgery and another type of treatment, the sequence of the two
treatments;
ff. The code for the
status of the patient's treatment, including whether the patient received any
treatment or the tumor was being actively observed and monitored;
gg. The code for whether the patient has had
a reappearance of a cancer, carcinoma in situ, or benign tumor of the central
nervous system, and, if additional cancer of the type diagnosed at the primary
site is found after cancer-directed treatment:
i. The date of the reappearance;
and
ii. A narrative description of
the nature of the reappearance, including whether the additional cancer was
found at the primary site, a regional site, or a distant site;
hh. If the patient has died, the place and cause of
death and whether an autopsy was performed;
ii. The name of the individual or the code
that identifies the individual completing the case report;
jj.
The type of records used by the reporting facility to complete the case
report;
kk. If applicable, a code
that indicates the reason for a required date not to be included in the case
report required in subsection (B)(1); and
ll. If applicable, a code that indicates that
an apparently inconsistent code has been reviewed and is correct; and
3. Use codes and coding
format supplied by the Department for data items specified in subsection (B)(2)
that require codes in the case report.
Disclaimer: These regulations may not be the most recent version. Arizona may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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