Mont. Admin. r. 37.8.1802

Current through Register Vol. 23, December 6, 2024

Rule 37.8.1802 - REQUIRED RECORDS, INITIAL ADMISSION AND TREATMENT

(1) Whenever a hospital initially provides medical services to any patient relating to a tumor designated as reportable by ARM 37.8.1801, it must collect, record, and make available to the department the following information about that patient:

(a) name and current physical address of patient;

(b) patient's physical address at time of diagnosis;

(c) social security number;

(d) name of spouse, if any;

(e) phone number;

(f) race, Hispanic origin if applicable, sex, and marital status;

(g) age at diagnosis, place of birth, and month, day, and year of birth;

(h) name, address, and phone number of friend or relative to act as contact, plus relationship of that contact to patient;

(i) date and place of initial diagnosis;

(j) primary site of tumor (paired organ);

(k) sequence of primary tumors if more than one;

(l) other primary tumors;

(m) method of confirming diagnosis;

(n) histology, including dates, place, histologic type and slide number;

(o) summary staging, including whether in situ, localized, regional, distant or unstaged, with no information, or whether AJCC or TNM staging is utilized, and, if so, the findings of this staging;

(p) description of tumor and its spread, if any, including size in centimeters, number of positive nodes, number of nodes examined and site of distant metastases;

(q) procedures done to diagnose or stage tumors including dates, procedures, and results (such as physical exams, scopes, x-rays, scans, or lab tests);

(r) cumulative summary of all first course therapy directed at the subject tumor, including:

(i) date of therapy;

(ii) specific type of surgery or radiation therapy, if any, and details of chemical, hormonal, or other kinds of treatment; and

(iii) if no therapy given, reason for lack of therapy.

(s) status at time of latest recorded information, i.e., whether alive or dead, tumor in evidence, or recurring, or status unknown;

(t) if recurrence of tumor, date, type, and distant sites of first recurrence;

(u) names of physicians primarily and secondarily responsible for follow up;

(v) date of each follow up;

(w) if patient has died, date of death, place, cause, and whether autopsy performed;

(x) primary payer at diagnosis;

(y) usual occupation and industry; and

(z) tobacco and alcohol use history.

(2) As used in this rule, "first course therapy" includes all methods of treatment recorded in the treatment plan and administered to the patient before disease progression or recurrence.

Mont. Admin. r. 37.8.1802

NEW, 1982 MAR p. 391, Eff. 2/26/82; TRANS, from DHES, 1997 MAR p. 1460; AMD, 2003 MAR p. 2441, Eff. 10/31/03; AMD, 2009 MAR p. 87, Eff. 1/30/09; AMD, 2023 MAR p. 304, Eff. 3/25/2023

AUTH: 50-15-706, MCA; IMP: 50-15-703, MCA