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.
- 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.
- Obtains copies of EMS reports from appropriate EMS agency as possible.
- Obtains copies of referring hospital medical record as possible
- 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.