JOB SUMMARY

The Trauma Registry Specialist is responsible for maintaining and completing current and accurate Trauma Registry (inpatient, outpatient trauma patient) databases, which contain patient-care information from the following phases of care : pre-hospital, emergency room, hospital course, and final outcome.

Completed work and decisions made are not reviewed when performed within established departmental guidelines. Work is assigned according to patient census data.

Work and decisions are subject to review when guidelines require extension and / or interpretation and when proposed solutions affect the work within the Department.

Guidelines include policies, procedures, and precedents of the Department, and MarinHealth Medical Center.

JOB SPECIFICATIONS : EDUCATION

EDUCATION

• High school graduate or equivalent
• College course work in business, computers, data-entry, or related fields is desirable

EXPERIENCE

• 1-2 years’ experience in abstracting data from medical records, preferably ED / Trauma related
• Experience in data collection using ICD-10 clinical manager codes preferred

KNOWLEDGE

• Knowledge of Microsoft Word, Excel, Access, and ability to set up data analysis
• Knowledge of medical / technical / diagnostic / procedural terminology required
• Knowledge of detailed computer data-entry, collection, and retrieval operations for spread sheets to include graphics in Excel and Trauma Database programs (Trauma One)
• Knowledge of practices, pre-hospital care, emergency and discharge information and characteristics of trauma patients
• Recognition of various diagnostic reports and chart orders
• Confidentiality and security concepts per hospital policies and procedures
• AIS 2005

SPECIAL SKILLS / EQUIPMENT

• Demonstrated ability to understand medical terminology and the ability to identify and abstract medical data from paper and electronic medical records
• Demonstrated ability to work accurately work accurately under department timelines, exercising good judgement with minimal supervision
• Strong typing and computer skills (data entry / retrieval techniques)
• Demonstrated computer and software troubleshooting skills, including spreadsheets and word processing
• Ability to read and interpret written and transcribed documents in the medical record, and ability to enter complete data into on-line computer system
• Excellent written and verbal communication / interpersonal skills and the ability to deal with individuals of varying comprehension levels
• Must possess tact and diplomacy skills to obtain information from a variety of hospital and public sources

LICENSE / REGISTRATION / CERTIFICATION :

Certified Trauma Registrar preferred

DUTIES AND RESPONSIBILITIES :

ESSENTIAL (not modifiable)

Abstracts data and data input supporting registry concurrency Abstracts data from multiple sources, including the patient medical record, admission logs and nursing recordsAbstracts from various patient records, required information including treatment during hospitalization, complications and hospital discharge statusInputs into database information on identified hospital course variables and hospital discharge variablesReviews data input to assure accuracy and completeness of Registry recordsPerforms data validation for accuracy and completeness of registry records.

Reviews medical record, interprets information, and enters complete and accurate data into on-line computer systemSubmits requests to Medical Records Dept.

for chart retrievalAssists in the management of daily operations of the trauma registry

• Assists with statistical reports in support of Trauma Program Operations and the Trauma Performance Improvement Program In collaboration with the Trauma Specialist, prepares required data for EMS / Trauma Committees for Marin County, State and Regional Trauma CommitteesAssists Trauma Specialist in preparing reports to support ongoing program planningProvides data input and reports to support and direct the Process Improvement Programs
• Monitors Compliance with Trauma Service standards of Patient Care Audits Trauma Registry in compliance with American College of Surgeon StandardsReports performance improvement issues to Trauma Program Manager / Trauma DirectorFollows through on research of performance improvement issues identified

SECONDARY (modifiable)

Last updated : 2024-06-20