The Trauma Registrar is responsible for the collection/abstraction of required state and national trauma data bank elements into the statewide trauma registry on all patients meeting state or national trauma inclusion criteria. The Trauma Registrar maintains the confidentiality of registry data and provides registry data as appropriate for research.

• Performs basic data collection of demographics and coding of clinical and follow-up data from all sources into trauma registry database
• Interacts with physicians, nurses, and other members of the trauma team and trauma patients to perform trauma registry functions
• Keeps registry current as defined by the American College of Surgeons (ACS) as 80% complete within 60 days of patient discharge
• Determines appropriateness of patient entry into the Trauma Registry based on guidelines in the American College of Surgeons “Resources for the Optimal Care of the Injured Patient” as well as the National Trauma Data Standard
• Provides high quality data entry by abstraction of required state and national trauma data elements from the patient chart in real time and retrospectively
• Participates in quality assurance, data validation, and improvement activities to ensure accuracy of data collection and timely submission of data according to State Trauma Registry and the American College of Surgeons Optimal Resource Document for Trauma Centers
• Understands mapping concepts and validates mapping of registry software for Trauma Quality Improvement Program (TQIP), National Trauma Data Bank (NTDB), and the state
• Resolves routine coding issues/problems and appropriately seeks assistance from Trauma Program leadership and/or Trauma Registry vendor when appropriate
• Recognizes patterns of mechanism and injury during case abstraction in order to contribute to opportunities for injury prevention and community safety
• Reports data in formats such as Excel and/or PowerPoint for both internal and external consumption (includes statistical, clinical, and research data)

Experience/Specialized Skills:

Work Experience:

• One (1) year coding experience OR previous experience working with trauma registry databases and handling medical information in a health care setting

Required Skills, Knowledge, and Abilities:

• Knowledge of and ability to use computers, including word processing, spread sheets, graphics, messaging (E-Mail), database management, and report writers
• Extensive knowledge of trauma registry maintenance and related regulations
• Knowledge of medical terminology, anatomy, and physiology
• Knowledge of data abstraction techniques
• Knowledge of ICD-10 Coding
• Ability to work independently on assigned projects and to recommend improvement to the process of collecting, maintaining, and reporting patient information
• Ability to establish productive relationships with a wide variety of health care professionals

Required Education/Course(s)/Training:

Knowledge of the following:

• Anatomy and Physiology
• Medical terminology
• Coding
• Data analysis
• Data management
• Participate in and pass the AAAM’s Abbreviated Injury Scale (AIS) course within 1 year of hire
• Participate in a trauma registry course that includes all of the following content within 1 year of hire:
  • Abstraction
  • Data management
  • Reports/report analysis
  • Data validation
  • HIPAA
• Participate in an ICD-10 course or an ICD-10 refresher course every five years
• Each trauma registrar must accrue at least 24 hours of trauma-related CE during the verification cycle

Preferred Certification/Registration:

• Certified Abbreviated Injury Scale Specialist (CAISS)
• Certified Specialist in Trauma Registries (CSTR)