Trauma Registrar, Part-Time Days

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Round Rock Medical Center Published: April 13, 2018
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Description

Under the direction of the Trauma Program Nursing Director, the Trauma Program Registrar is responsible for abstracting data from identified trauma patient medical records. This position utilizes expertise in computer data entry to maintain an accurate database that is utilized for performance improvement activities, injury prevention and information requests.  Registry data is also submitted to state and national trauma data bases.

Job Responsibilities

1. The Trauma Registrar is responsible for abstracting specific information from the hospital records of injured patients and coding injuries as required to complete data entry into the trauma registry within 30-60 days of patient’s discharge from the hospital.
  • Abstracts data from patient hospital records in order to assign appropriate coding:
    •  Adult Injury Severity (AIS) coding
    • ICD-10 diagnosis codes
    • Complications/morbidity coding per the list in the trauma registry
    •  Coding performance improvement indicators as required by the American College of Surgeons and the Trauma Quality Improvement Program (TQIP)
    • Maintains the integrity of the trauma registry by utilizing the data dictionary provided by the National Trauma Data Bank and rules provided by the American College of Surgeons and the State of Texas.
    • Active participation in TQIP webinars and conference calls
    • Strict adherence to the TQIP data entry guidelines
    • Conduct data validation
  • Maintains the confidentiality of the trauma registry by logging off the computer when not entering data, not sharing computer password with anyone and not sharing protected health information with anyone other than those involved in the care of trauma patients.  Prepares trauma registry reports as requested.
  • Ensures medical records are pulled and available for monthly peer review meetings and other meetings or conferences as requested.
2.  The Trauma Registrar is responsible for obtaining and securing documentation from outside agencies as needed to complete data entry/performance improvement monitors for the trauma registry.
  • Obtains copies of EMS reports from appropriate EMS agency as possible.
  • Obtains copies of referring hospital medical record as possible
3. Performance Improvement functions:
• Develop and run reports in the trauma registry daily, monthly, quarterly, and annually as required for TQIP, ACS survey preparation and the trauma department PI dashboards to include charts and graphs in Microsoft Excel
4. ACS survey preparation on a continual basis

Job Requirements

KNOWLEDGE, SKILLS AND ABILITIES:
Ability to communicate clearly and effectively: excellent oral and written communication skills; ability to relate to diverse populations in an open, friendly and accepting manner; ability to make timely and sound decisions under conditions of uncertainty; ability to handle stressful situations.  Management of conflicting priorities; problem solving, team building; comfort level with ambiguity and autonomy; ability to facilitate effective working relationships to achieve established goals and objectives; role models values of St. David’s Health Care System.  Must be able to demonstrate understanding of HCA’s and St. David’s “Patients First” safety initiative by strict compliance to all safety protocols and procedures.
  • Demonstrates respect, courtesy and empathy to all individuals: patients, families, coworkers, physicians and volunteers.  Maintains positive work relationships and contributes to a team environment.  Maintains regard for patient rights.
  • Quality – Demonstrates respectful and appropriate language and nonverbal behavior.  Actively seeks to resolve issues, problems and concerns.
  • Communication and Timeliness: Communicates information and resolves customer concerns in a timely manner.
  

Qualifications

 

EDUCATION AND EXPERIENCE:
 
Required:         High School Diploma and Experience in medical terminology or medical record coding.
Preferred:         One or more years experience as a Trauma Registrar in Level III or higher trauma center. Experience with Trauma-Base Registry software.
LICENSES AND CERTIFICATES:
Required:         Certified Trauma Registrar or goal to obtain within 2 years of employment
Preferred:         Certified Trauma Registry
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