Ariz. Admin. Code § 9-4-403

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-4-403 - Case Reports

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.

Ariz. Admin. Code § R9-4-403

Adopted effective January 1, 1992, filed September 25, 1991 (Supp. 91-3). Section repealed; new Section made by final rulemaking at 12 A.A.R. 179, effective March 11, 2006 (Supp. 06-1). Amended by final rulemaking at 12 A.A.R. 3708, effective November 11, 2006 (Supp. 06-3). Amended by final rulemaking at 25 A.A.R. 3429, effective 1/1/2020.