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CTC Exam Form

The CTC Exam Form is used to collect all patient demographic information and exam/polyp information in a consolidated form. You can also access the exam form by clicking Register New Exam under Data Management in the CTC Registry menu, and entering in the patient information to search for, or create a new exam.




Complete the form by selecting from among the options presented on the form and filling in the blank fields. Fields marked with an asterisk (*) must be entered or the form cannot be submitted. Specific instructions for each field are as follows below.


Select the appropriate response. 

Field Name

Description

Facility ID Number


Registry Case Number


These fields are filled in automatically from the case registration form.

Case Registration Date


Enter the date the paper form was completed.


3. Patient Information

SSN

To use the patient’s SSN, select the SSN radio button and enter the ID in the format NNN-NN-NNNN where N is a digit; all digits are required. (Note: Hyphens are not required for file upload submissions).

Use Other Identification


Description


Enter the Other Identification field, and a description of the code, such as Social Insurance Number, in the Description field. Entries in these fields cannot exceed 50 characters. 

*Last Name

*First Name


First and last names must be 45 characters or less. At least two characters must be from the characters "A"-"Z", "a"-"z", or a single quote ('). Additional characters may include a hyphen.

Middle Name


Middle Name is optional. If entered, it must start with a letter. The remaining characters can be letters, or the characters" ' ", "-", or "."

Old Medicare Beneficiary ID (MBID)


Indicate the the patient's Medicare Beneficiary ID issued prior to April 2018. The format is primarily numeric, with 1-2 letters proceeding or following them.

New Medicare Beneficiary ID (MBID)


Indicate the the patient's Medicare Beneficiary ID issued after April 2018. This will usually be a combination of letters and numbers, 11 characters long.  

*Date of Birth


Date of Birth must be at least three weeks prior to the current date.


*Patient Sex


Select the appropriate response.


Race


Enter the patient’s race as identified by the patient. If the patient identifies with more than one race, select Other. This field is optional.

Patient Ethnicity (Hispanic Origin)


Enter whether the patient is of Hispanic origin, as identified by the patient. This field is optional.

Health Insurance


Select the version of health insurance of the patient, if available.


Education level


Select the patient's level of education, if available.


COVID vaccination/vaccination date


Indicate if the patient has received the COVID vaccine and the date of vaccination, if available.


COVID vaccine manufacturer

Select the appropriate response.

COVID vaccine site

Enter the location where the patient received the COVID vaccine, if available.

*Examination Date

Enter the date the exam was completed in mm/dd/yyyy format. The date must not be greater than the current date.

5. General Information

*Type of Study

Select the appropriate response.

*Interpreting Physician


The physician’s name must be selected from the drop-down list. For a physician to be listed as the interpreting physician, he or she must be listed as a CTC participant in the physician dictionary. Refer to Manage Physicians and Add Physicians to an Individual Registry for instructions on listing a physician as a CTC participant.


Did technique meet ACR guidelines?

Select the appropriate response. Click the Question mark Help Icon.png icon for details.

Referred from incomplete colonoscopy

Select the appropriate response.

*CTDIvol

Enter the CTDIvol in mGy as displayed on the console. Range: 0.01 – 999.99.

*Supine image acquisition



*Prone image acquisition



*Decubitus image acquisition

Select the appropriate response.

B. Post Examination and Adverse Events

*At least one polyp >= 10 mm

Select the appropriate response. 

*Colonic perforation

If Yes is selected then etiology, location, and whether patient was symptomatic from perforation must be indicated.

C Score    

Select the appropriate response.

E Score    

Select the appropriate response.


Click the Submit button when the form is complete. You must correct any errors or the form will not be accepted by the registry. If no errors are detected a confirmation message appears and the case moves to Completed status. 



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