Trauma Registrar

This position is accountable for the collection, completion, and verification of the accuracy of all patient data collected for the Trauma Registry data collection system. The Registrar creates and maintains clinical and statistical data, AIS coding, ICD10CM codes and abstracts various data elements required ensuring consistency and quality in all aspects of the system through data collection. Responsibilities include daily monitoring of trauma admissions for record identification; abstracting, coding and entering data into the registry. Retrieves registry data for quality improvement and research to provide accurate statistical trauma data. The Trauma Registrar is responsible for coordination of billing and reimbursement data with billing office.

• Medical Records and Coding
• Identifies the trauma patient medical records. Monitors Emergency Department, Admitting department, and Trauma Team activation pages on a daily basis for trauma admissions.
• Performs concurrent/retrospective abstraction from the trauma patients medical record of relevant information required for the Trauma Registry. Takes initiative for finding lost information. This includes contacting pre-hospital care agencies for missing run sheets.
• Abstracts core information from patient medical records (including demographic characteristics, history of injuries, diagnostic procedures and treatment, laboratory values and medical complications) and enters select information from trauma patient records to Trauma 1 database.
• Accurately assigns codes including diagnoses and procedures using ICD-10-CM and CPT4 guidelines. Determines the appropriate sequencing of diseases, diagnoses, and surgeries. Coordinates all patient charges to assure appropriate billing and reimbursement.
• Maintains the computerized Trauma Registry system which includes keeping data updated and making additions/corrections, downloading and sending data to the National Trauma Data Bank. Works with software vendor and hospital IS department for updates to the registry to maintain current data element collection and to correct problems.
• Quality and Performance Improvement
• Prepares and tabulates monthly and annual statistics. Prepares reports from the Trauma registry data and presentations of these statistics for quality improvement, research, to monitor new trends in trauma care and for Trauma Peer Review M&M Committee.
• Assists with organization and participates in committees such as: Trauma M&M Conference and Trauma Operations meetings.
• Participates in various research projects as needed in the department through data collection methods to extract vital information pertaining to the trauma program related to objectives and reporting requirements.
• Maintains continuing education related to trauma registry and PI.
• Other Duties As Assigned
• 1-2 years of ICD and/or AIS acute care coding experience.
• LPN with five (5) years ED or Acute Care bedside experience may substitute for 1-2 years of ICD 10 and/or AIS acute care coding.
• Associate's degree in Health Information Management or a related field. Five (5) years ED or Acute Care bedside experience may substitute for Associates Degree.
• Successful completion of the Trauma Registry Course is required within the first year of employment.