Physician Practice Cancer Case Tracking Log
[Practice Name]
Enter each patient identified with a reportable cancer.
Have patient chart/medical record available when using on-line reporting form.
See attached instructions for additional information
Date of
Diagnosis
Date of
First Visit
Hospital Admit
(Y/N)
Hospital
Admit Date
Medical
Record #
Last Name
First Name
Date of Birth
Type of Cancer/
Primary Site
ICD-10-CM
(or ICD-9-CM)
Date Submitted
to NYSCR
Reason not
Submitted to NYSCR
Comments
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Instructions - Physician Practice Tracking Log
1. Date of Diagnosis
Enter the date the patient was first diagnosed with this reportable cancer.
2. Date of Visit
Enter the date the patient was first seen with this reportable cancer.
3. Hospital Admit (Y/N)
If the patient is admitted to a hospital as an inpatient for this cancer, mark "Y".
If the patient is not admitted to a hospital as an inpatient or it is unknown if admitted to a hospital for this cancer, enter "N". This needs to be reported.
4. Hospital Admit Date
Enter date of a hospital admission as an inpatient for treatment of this cancer.
Leave blank, if the patient is not admitted to a hospital as an inpatient for treatment of this cancer.
5. Medical Record #
If available, enter the patient’s physician office medical record number.
6. Last Name
Enter the patient’s last name.
7. First Name
Enter the patient’s first name.
8. Date of Birth
Enter the patient’s date of birth.
9. Type of Cancer/Primary Site
Enter the site of the body that the tumor originated. (Note: For many hematopoietic malignancies, including leukemia, the site is the bone marrow.)
10. ICD-9-CM Code
If available, enter the ICD-9-CM code.
11. Date submitted to NYSCR
Enter the date the abstract is submitted to the NYSCR.
12. Reason not submitted to NYSCR
If applicable, enter the reason the case was not reported to the NYSCR.
13. Comments
Enter additional information here.
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