Instructions and Reporting Requirements Appendix B Electronic Reporting For Dermatology Physician Practices March 2014 North Carolina Central Cancer Registry State Center for Health Statistics Division of Public Health Department of Health and Human Services 1908 Mail Service Center Raleigh, NC North Carolina Central Cancer Registry

Appendix B Physician Practice Casefinding Tracking Log

Appendix B: Casefinding Tracking Log Appendix B: Physician Practice Casefinding Tracking Log

Appendix B: Casefinding Tracking Log Appendix B: Physician Practice Casefinding Tracking Log Instructions for completing the Physician Practice Tracking Log General Instructions: Record all cases identified through reports/patient logs included in the casefinding process. This includes reportable and non-reportable cases. If a patient has two or more independent cases of cancer, the patient will need to be entered multiple times, once for each primary. If this tumor for the patient has already been reported, you do not need to enter the information again on the form. You may use the comments section to record additional notes if necessary. You may also update the "Last Date Record Reviewed.” Medical Record # If available, enter the patient’s physician office medical record number. Last Name Enter the patient's last name. First Name Enter the patient's first name. Date of Birth Enter the patient's date of birth. ICD-9-CM Code If available, enter the ICD-9-CM code. Type of Cancer/Primary Site Enter the site (organ, tissue, etc.) of the body where the tumor originated. Date of Diagnosis Enter the date a medical practitioner first stated this patient has a reportable cancer or condition. Date of First Visit Enter the date the patient was first seen at this office with this reportable cancer.

Appendix B: Casefinding Tracking Log Appendix B: Physician Practice Casefinding Tracking Log - continued Instructions for completing the Physician Practice Tracking Log - continued Last Date Patient Record Reviewed Enter the last date the patient's record was reviewed. This can be extremely helpful in not having to re-review information from previous visits. Date Entered/Submitted to NCCCR Enter the date the case report was entered into the physician dermatology report form and therefore submitted to the NCCCR. Leave blank if the case is not reportable. Record “Incomplete” if a final decision has not been made and further information is needed.

Appendix B: Casefinding Tracking Log Appendix B: Physician Practice Casefinding Tracking Log - continued Reason not Submitted to NCCCR / Comments For cases that were determined not to be reportable, enter the reason the case was not reported to the NCCCR. Examples include: Seen at ____ Hospital. Not a reportable condition PIN III, Case already reported, Waiting on upcoming visit for final diagnosis, etc. Enter additional information here that will assist the reporter in future casefinding efforts. It can be especially helpful to document that a final decision cannot be made. For example, the information in the record was incomplete and additional information from the physician or information from a future visit is needed. Enter the North Carolina hospital name if it is documented that the patient was seen at that North Carolina hospital for the management of this cancer. Leave blank if the patient was not seen at a North Carolina hospital (or it is unknown) for the management of this cancer. This case needs to be reported. Enter the visit date (inpatient or outpatient) at that hospital for the diagnosis or treatment of this cancer. Leave blank if the patient was not seen at a NC hospital (or it is unknown) for the management of this cancer.

Appendix B Completed