CTC Case Registration Form
Modified on: Wed, 16 Jan, 2019 at 9:43 AM
Printing the Form
You can view and print the CTC Case Registration form by clicking Case Registration Form under Forms and Data Dictionary in the CTC Registry menu. You may print and complete a hardcopy form to help with your workflow and organization.
Accessing the Form
To access the online data entry form, select Register New Case from the Data Collection Menu. If you need to update a form already in progress, select Registration from the Data Collection menu. You can use the Filter to find a case using criteria for case information, patient information, and physician information. Click on the case number link, in the first column, to open and edit the case.
Completing the Form
Complete the form according to the instructions, below. Fields marked with an asterisk (*) must be entered or the form cannot be submitted.
This field is filled in automatically.
Case Registration Date
Enter the date the paper form was completed.
This field is filled in automatically. If the patient already exists in the patient dictionary, click thebutton on the search bar:
The following box appears:
Select the radio button next to the desired search field (Patient ID, SSN, or other ID), enter the criterion, and click the Find button. If the patient record is found, all fields in Section 1 of the Case Registration form will automatically be filled in from the patient dictionary. If the patient does not already exist in the patient dictionary, enter the patient information described, below, to create a new patient record.
*SSN or Other ID
Either the patient’s social security number (SSN) or some other identification code must be provided, but not both.
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.
Use Other Identification
If you do not provide the social security number, click the button next to Use Other Identification. Enter the identification code in the Use 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. Do not enter the Use Other Identification or Description fields if the social security number is provided.
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 is optional. If entered, it must start with a letter. The remaining characters can be letters, or the characters" ' ", "-", or "."
*Date of Birth
Date of Birth must be at least three weeks prior to the current date.
Select the appropriate response.
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.
Enter the date the exam was completed in mm/dd/yyyy format. The date must not be greater than the current date.
Name of Person Who Completed the Paper Form
Enter the name of the person who collected the data for this exam. If this name has not been previously entered in a case record, select Add New and enter the person’s first and last name. In the future, the name will appear in the drop-down list for this field. If the name has been previously entered, click the arrow and select it from the drop-down list.
Note: Please populate this field even if paper forms were not used; you may use the name of the person completing the on-line data submission.
To delete a name from the list, select it and then click the Delete Person button.
Name of person submitting form
These fields are filled in automatically.
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