Section R9-4-403. Case Reports

A.      A physician, doctor of naturopathic medicine, dentist, regis- tered nurse practitioner, or the designee of a clinic shall:

1.        Prepare a case report in a format provided by the Depart- ment;

2.        Include the following information in the case report:

a.         The name, address, and telephone number, 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 can- cer being reported;

f.         The patient’s usual industry and usual occupation, if the patient is an adult;

g.        The patient’s medical record number, if assigned;

h.        The date of diagnosis of the cancer being reported;

i.         If the diagnosis was not made at the reporting facil- ity, the name and address of the facility at which the diagnosis was made;

j.         The primary site and subsite of the cancer being reported;

k.        The tumor size, histology, grade, and laterality at diagnosis;

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;

p.        Whether the diagnosis was made by histology, cytol- ogy, clinical evaluation, diagnostic x-ray, or any other method, or whether the method by which the diagnosis was made is unknown;

q.        For each treatment the patient received, the type of treatment, date of treatment, and the name of the facility where the treatment was performed;

r.         Whether any residual tumor cells were left at the edges of a surgical site, after surgery to remove a tumor at the primary site;

s.         Whether the patient is alive or dead, including the date of last contact if the patient is alive, and the date, place, and cause of death if the patient is dead;

t.         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;

u.        The name of the physician, nurse practitioner, or doctor of naturopathic medicine providing medical services, as defined in A.R.S. § 36-401, to the patient;

v.        The name of the individual or the code that identifies the individual completing the case report;

w.       The date the case report was completed; 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 Depart- ment for data items specified in subsection (A)(2) that require codes on the case report.

B.       The cancer registry of a hospital with a licensed capacity of fewer than 50 inpatient beds that reports as specified in R9-4- 404(A) and the cancer registry of a hospital with a licensed capacity of 50 or more inpatient beds shall:

1.        Prepare a case report in a format provided by the Depart- ment;

2.        Include the information specified in subsection (A) and the following information on the case report:

a.         The patient’s accession number;

b.        The sequence number of the cancer 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 hospi- tal 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 diagno- sis or treatment, or both, of the patient for cancer;

g.        The year in which the hospital first provided diagno- sis 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.        The patient’s religious preference, if applicable;

l.         Whether the patient’s laboratory results show the presence of specific substances known as Tumor Marker 1 and Tumor Marker 2, which are derived from tumor tissue and whose detection in the blood of a human body indicates the presence of a specific type of tumor;

m.       A narrative description of how the cancer was diag- nosed;

n.        The number of regional lymph nodes examined and the number in which evidence of cancer was detected;

o.        The clinical or pathological staging classification, based on the analysis of tumor, lymph node, and metastasis;

p.        The patient’s clinical or pathological stage group;

q.        The occupation of the individual who determined the clinical or pathological stage group of the patient;

r.         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;

s.         A narrative description of laboratory tests performed for the patient, including the date, type, and results of any of the patient’s laboratory tests;

t.         A narrative description of the results of the patient’s clinical evaluation;

u.        The procedures used by the reporting facility to obtain a diagnosis and staging classification, includ-

ing the dates on which the procedures were per- formed, and the name of the facilities where the procedures were performed, if different from the reporting facility;

v.                 A narrative description of any cancer-related surgery on the patient, including the date of surgery, name of the facility where the surgery was performed, if dif- ferent from the reporting facility, and type of sur- gery;

w.              The code associated with the type of surgery per- formed on the patient and the date of surgery;

x.                 The codes associated with the:

i.         Surgical approach;

ii.        Extent of lymph node surgery;

iii.      Number of lymph nodes removed;

iv.       Surgery of regional sites, distant sites, or distant lymph nodes; and

v.        Reason for no surgery or that surgery was per- formed;

y.                 Whether reconstructive surgery on the patient was performed as a first course of treatment, delayed, or not performed;

z.                  A narrative description of cancer-related radiation treatment administered to the patient, including the date of radiation treatment, name of the facility where the radiation treatment was performed, if dif- ferent from the reporting facility, and type of radia- tion;

aa. The code associated with the type of radiation treat- ment administered to the patient and the date of radi- ation treatment;

bb. A narrative description of cancer-related chemother- apy administered to the patient, including the date of cancer-related chemotherapy, name of the facility that administered the chemotherapy, if different from the reporting facility, and type of chemother- apy;

cc. The code associated with the type of chemotherapy administered to the patient and the date of chemo- therapy;

dd. If the patient’s treatment included both surgery and radiation treatment, the sequence of the two treat- ments;

ee. If applicable, a narrative description of 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.         Additional surgery, chemotherapy, radiation, or other treatment, administered to the patient;

ii.       The dates of the treatment;

iii.      The names of the facilities where the treatment was performed, if different from the reporting facility; and

iv.      The type of treatment;

ff. If additional cancer of the type diagnosed at the pri- mary site is found after cancer-directed treatment, the date and location of the additional cancer, and whether the additional cancer was found at the pri- mary site, a regional site, or a distant site;

gg. If the patient has died, whether an autopsy was per- formed; and

hh. The type of records used by the reporting facility to complete the case report; 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.

Historical Note

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).