"Hospice Reporting Form - Puerto Rico Central Cancer Registry"

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PRCCR Use Only
Y-CRS No._________________________ UPDate____________________
PUERTO RICO CENTRAL CANCER REGISTRY
HOSPICE REPORTING FORM
N-CRS
F/UP Date_________________ Letter Call
NO INFO Abstract Hold Processed by___________________________
Institution’s Information
Name of institution: ______________________________________ Attending MD_______________________________
Within Institution
(
)
Address_____________________________________________________________Phone # (___) __________________
Patient’s Information
Patient’s Name __________________________________________________ Date of Birth _______________________
(
)
Paternal & Maternal last names, Name, Middle name
MM/DD/YYYY
(
)
Social Security No. ___________________ MS □
Sex □
Single
Married
eparated
Divorced
Widowed
Unknown
Male
Female
Other
S
Phone # (___) _________________
Patient’s Address ____________________________
(Please select type of address) (Note: Please provide physical instead of postal address)
__________________________________
____________________________________
Patient’s home
Patient’s home
__________________________________
____________________________________
Relative
Relative
__________________________________
____________________________________
Nursing home
Nursing home
Diagnosis Information
Organ/system where cancer is located ___________________________Type of cancer______________________________________
(For example: Colon, Breast, Prostate, Blood, Lymph nodes)
(For example: Adenocarcinoma, Melanoma, Sarcoma, Brain tumor, Leukemia)
Additional information_________________________________________________________________________________________________
(Evidence of treatment)
Surgery
Chemotherapy
Radiotherapy
Other
Date FIRST DIAGNOSED ______________________ MD_____________________________________
(outside institution)
(MM/DD/YYYY)
(If the exact date on which the diagnosis was made is not available, then record an approximate date. Do not leave blank)
Follow Up Information
Patient was transferred from:
□ Patient’s home □ Hospital □ Nursing home □ Other (Specify)
__________________________________________________________
Name of Institution
Physician: ______________________________________
Address
__________________________________________ Phone # (
)
__________________________________________
Patient was transferred to
□ Patient’s home □ Hospital □ Nursing home □ Other (Specify) ______________________________________________________
Name of Institution __________________________________________________________________________________
Date of last contact with the patient __________________________ Vital Status □
Alive
Dead
(MM/DD/YYYY)
Form completed by ____________________________________ Position_________________________
(Please PRINT)
Date _____________________
(MM/DD/YYYY)
PRCCR 016 – Hospice Reporting Form
Rev. 04/2010
PUERTO RICO CENTRAL CANCER REGISTRY
PMB 711 Ave. De Diego #89 Suite105 San Juan, PR 00927-6345
Phone: (787) 772-8300 ext. 1103 Fax: (787) 522-3283
PRCCR Use Only
Y-CRS No._________________________ UPDate____________________
PUERTO RICO CENTRAL CANCER REGISTRY
HOSPICE REPORTING FORM
N-CRS
F/UP Date_________________ Letter Call
NO INFO Abstract Hold Processed by___________________________
Institution’s Information
Name of institution: ______________________________________ Attending MD_______________________________
Within Institution
(
)
Address_____________________________________________________________Phone # (___) __________________
Patient’s Information
Patient’s Name __________________________________________________ Date of Birth _______________________
(
)
Paternal & Maternal last names, Name, Middle name
MM/DD/YYYY
(
)
Social Security No. ___________________ MS □
Sex □
Single
Married
eparated
Divorced
Widowed
Unknown
Male
Female
Other
S
Phone # (___) _________________
Patient’s Address ____________________________
(Please select type of address) (Note: Please provide physical instead of postal address)
__________________________________
____________________________________
Patient’s home
Patient’s home
__________________________________
____________________________________
Relative
Relative
__________________________________
____________________________________
Nursing home
Nursing home
Diagnosis Information
Organ/system where cancer is located ___________________________Type of cancer______________________________________
(For example: Colon, Breast, Prostate, Blood, Lymph nodes)
(For example: Adenocarcinoma, Melanoma, Sarcoma, Brain tumor, Leukemia)
Additional information_________________________________________________________________________________________________
(Evidence of treatment)
Surgery
Chemotherapy
Radiotherapy
Other
Date FIRST DIAGNOSED ______________________ MD_____________________________________
(outside institution)
(MM/DD/YYYY)
(If the exact date on which the diagnosis was made is not available, then record an approximate date. Do not leave blank)
Follow Up Information
Patient was transferred from:
□ Patient’s home □ Hospital □ Nursing home □ Other (Specify)
__________________________________________________________
Name of Institution
Physician: ______________________________________
Address
__________________________________________ Phone # (
)
__________________________________________
Patient was transferred to
□ Patient’s home □ Hospital □ Nursing home □ Other (Specify) ______________________________________________________
Name of Institution __________________________________________________________________________________
Date of last contact with the patient __________________________ Vital Status □
Alive
Dead
(MM/DD/YYYY)
Form completed by ____________________________________ Position_________________________
(Please PRINT)
Date _____________________
(MM/DD/YYYY)
PRCCR 016 – Hospice Reporting Form
Rev. 04/2010
PUERTO RICO CENTRAL CANCER REGISTRY
PMB 711 Ave. De Diego #89 Suite105 San Juan, PR 00927-6345
Phone: (787) 772-8300 ext. 1103 Fax: (787) 522-3283
Instructions for Hospice Reporting Form
Institution Information
Name of institution: name of the reporting facility
Attending physician: complete name of the physician in charge of the patient in your facility
Address: institution address
Phone: phone number of the reporting facility
Patient Information
Patient’s name: please provide the complete name of the patient (include both last names and middle name when
available)
Date of birth: please provide the patient’s date of birth
Social Security number: please provide the patient’s social security number
Marital Status (MS): please select the appropriate option
Sex: please select the appropriate option
Address: we provide writing space for up to two addresses. Please provide the patient’s physical address
(municipality, urbanization, barrio, sector) as detailed as possible.
Phone: provide the phone number of the patient
Diagnosis Information
Organ/system where the cancer is located: please specify where in the body the cancer is located. For example:
Right Breast, Left Lung, Prostate, Ovary, Uterus, Blood, Lymph nodes, Pancreas, Liver.
Type of cancer: please specify the type of cancer. Consult with the attending physician if needed. For example:
Adenocarcinoma, Leukemia, Lymphoma, Brain tumor, Sarcoma, Multiple Myeloma, Melanoma.
Additional information: please provide any information regarding treatment, for instances, surgery as mastectomy
or colectomy, chemotherapy, radiotherapy or hormones.
Date first diagnosed: please provide the date when the patient was FIRST diagnosed with the cancer. If no exact
date is available then record an approximated date. DO NOT LEAVE BLANK.
MD: provide the complete name of the physician in charge of the patient OUTSIDE your facility or the physician
of the first diagnosis
Follow Up Information
Patient was transferred from: select the appropriate option. Where is the patient coming from?
Name of institution: provide the name of the institution, if applicable, where the patient is coming from.
Address: provide the address of the institution where the patient is coming from
Phone: provide the phone number of the institution where the patient is coming from
Patient was transferred to: select the appropriate option. Where is the patient going to?
Name of institution: provide the name of the institution, if applicable, where the patient is going to.
Date of last contact with the patient: record the most recent date.
Vital Status: select the appropriate option
Form completed by: provide the name of the person filling this form
Position: provide the position of the person filling the form, for example, registrar, supervisor, data clerk.
Date: provide the date when the form was completed
PRCCR 016 – Hospice Reporting Form
Rev. 04/2010
PUERTO RICO CENTRAL CANCER REGISTRY
PMB 711 Ave. De Diego #89 Suite105 San Juan, PR 00927-6345
Phone: (787) 772-8300 ext. 1103 Fax: (787) 522-3283
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