Analyzes codes and abstracts comprehensive, accurate clinical data relating to trauma patients and transcribes data into the Trauma Registry, utilizing all available sources of information to complete abstracts in a timely manner. Provides registry and quality improvement data in useful formats as requested.
Assists in meeting preparation for Trauma Program, maintaining files and documentation as required. Reviews log book and trauma alert log for trauma registry patients. Obtains reports for direct admissions and Outpatient surgery patients. Assists the Trauma Coordinator with loop closure and assists with entry into the registry.
High school graduate or G.E.D. preferred. One year experience in specialty preferred.
One year experience in medical records as coder preferred. Previous experience in quality improvement activities preferred. Previous experience in database management preferred with data entry. Ability to follow directions with minimal direct supervision. Able to analyze chart data and make decisions with sound judgment.
Computer skills with aptitude for data manipulation through database, spreadsheet, and graphics software.
Knowledge of anatomy and medical terminology preferred.
WORKING CONDITIONS/PHYSICAL DEMANDS:
- Use a computer keyboard, monitor and mouse and be able to use and apply hospital software programs.
- Answer telephones and use patient call system.
- Communicate verbally, written and electronically with healthcare personnel, families and patients.
- May be required to travel between facilities/buildings.
- May be exposed to virus, disease, and infection from patients and specimens in working environment.
- May be exposed to traumatic situations including psychiatric crisis, physical injuries and death.
- Must meet Department of Labor’s MEDIUM duty standard (MEDIUM WORK- exerting up to 50 pounds of force occasionally, and/or up to 20 pounds of force frequently, and/or up to 10 pounds of force constantly).
- Able to bend, stoop, reach and be capable of normal rotation, standing and walking for an 11-12 hour shift.
- Able to lift 40 pounds from floor to waist.
- This position may require unsupervised access to restricted areas that may contain medications, supplies and patient confidential information.