The Trauma Registrar II is responsible for the trauma registry, a data base unique to trauma patients. This includes identification, collection, coding, scoring and entering of data into a designated registry data base. The registrar assumes the responsibility of assuring the accuracy of the data that is collected and collaborates with performance improvement, administrative planning and marketing, prevention, outreach, support programs and research activities. The Trauma registrar II participates in Trauma Committee and quarterly state trauma meetings, providing data and interpreting reports as needed. This person ensures that trauma data is retrieved, entered, and supports the Trauma Data Analyst in accordance with state and national mandated regulations to ensure that NHRMC maintains Trauma Center verification. Assists with quality improvement activities, information requests and studies as requested. The Trauma Registrar II demonstrates an expertise level of trauma registry data abstraction, collection, entry, interpretation and analysis. Trauma Registrar II demonstrates independent initiative in trauma registry problem solving with minimal guidance of the Trauma Program Director. Is accountable for all entry, processing, audits, and inter-rater reliability activities. Highly involved with data downloads and upgrades and assures education to Trauma Services team of update changes or processes. Verifies Trauma, Orthopedic and other specialty team scheduling issues and ensures that all call schedules are current and accurate in the call database. Identifies and reports performance issue trends in a timely manner ongoing to Trauma Services team.
1. Identifies trauma patients, maintains log, performs chart abstracts, maintains ICD-9CM, (ICD 10), AIS coding, and enters data into database. 2. Obtains on-going follow-up information as needed, i.e. readmissions and autopsy results to close records. 3. Collaborates with the SERAC Regional Trauma, Injury Prevention, and Performance Improvement Trauma Coordinators to support PI activities in collaboration with the Trauma Data Analyst to provide requested information, support additional data capture. 4. Organizes, enters and maintains patient computer data to ensure conformance to trauma registry operational standards and to meet the needs of the users of the registry data. Maintains active participation in the Trauma Committee and the performance improvement process. 5. Enters data from the electronic medical record and associated documents into the Trauma Registry and various trauma related databases. 6. Facilitates data research and collaborates with the Trauma Medical Director, Trauma Program Director, Trauma Program Analyst, and other trauma team members. 7. May attend trauma rounds and or trauma activations to facilitate data abstraction and performance improvement documentation in the trauma registry. 8. Accountable for data download deadlines to state and national regulatory and accreditation organizations to maintain regulatory compliance, accreditation and qualitative comparisons to other trauma centers. Maintains a plan to ensure timely downloads and deadlines met. 9. Assists with trauma registry upgrades and special projects as requested. 10. Participates in monthly audits and other quality assurance activities to ensure accuracy of trauma registry data. 11. Monitors and reports information technology problems to vendors and director; make recommendation for improvements. Maintains and demonstrates professional competency, according to state regulations, department policies, procedures and protocols. 12. Assists Trauma Services Team in coordination of all data required for the Trauma Site Surveys. 13. Effectively demonstrates the mission, vision, values and culture of service and operational excellence supported by the medical center. 14. Preserves the confidentiality and security of patient data stored in the trauma registry files. Participates in educational activities of local, state and national Trauma associations, maintains required trauma educational hours. Reviews reference material and current literature relative to Trauma Registry. 15. Independently researches and solves complex coding problems or registry issues, collaborating with team/TPD, TMD, vendors, state, regional & national customers.
* CertSpecialist Trauma Registr
* High School Diploma
Education: Minimum of high school diploma, Associate Degree in Health Information Management related degree preferred, or minimum of 2-3 years medical experience. Working knowledge of medical terminology, anatomy and physiology or equivalent on-the-job training and ICD-9,(ICD 10) coding required. Must attend or have previously attended the American Trauma Society’s Trauma Registrar Course or equivalent provided by a state trauma program and the Association of the Advancement of Automotive Medicine’s Injury Scaling Course within 12 months of hire.
Licensure / Certifications: Certification in CSTR, (Certified Specialist in Trauma Registry) is preferred. AIS (Abbreviated Injury Severity Score) required.
Experience: 2-3 years Trauma Registry or data registry required. Emergency Medical Services, (EMS), Emergency Department, Operating Room or Critical Care preferred. Previous trauma registry and or medical record coding required. One to two years experience with databases and statistical analysis required. Basic Keyboarding/data entry and basic Windows base software required. 4. Skills and Abilities: Organizational skills with good follow through. Investigative/analytic skills with detail orientation. Professional verbal and written communication skills.
Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
Performs other duties as assigned.
Individual will possess commensurate combination of education, experience and qualifications.