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

Current through Register Vol. 30, No. 28, July 12, 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.