New Hanover Regional Medical Center Trauma Registrar I - Trauma Services in Wilmington, North Carolina
Trauma Registrar I - Trauma Services
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This position has access to and knowledge of extremely sensitive, private and confidential materials. Ability to maintain the highest standard is required with zero tolerance. All the primary duties within this document will be performed according to established policies, procedures and guidelines within the department and the Medical Center. JOB SUMMARY: The Trauma Registrar I is responsible for the trauma registry, a data base unique to trauma patients. This includes identification, collection, coding, scoring and entering of data into a designated registry data base.The registrar assumes the responsibility of assuring the accuracy of the data that is collected and collaborates with performance improvement and administrative planning. This person ensures that trauma data is retrieved, entered, analyzed and verified in accordance with state and national mandated regulations to ensure that NHRMC maintains Trauma Center status. Assists with quality control activities, information requests and studies as requested. PRIMARY JOB DUTIES: 1. Identifies trauma patients, maintains log, performs chart abstracts, maintains ICD-9CM, (ICD 10), AIS coding and enters data into database. 2. Obtains on-going followup information as needed, i.e. readmissions and autopsy results to close records. 3. Collaborates with the SERAC Regional Trauma and Performance Improvement Trauma Coordinators to obtain end results of information. 4. Organizes, enters and maintains patient computer data to ensure conformance to trauma registry operational standards and to meet the needs of the users of the registry data.. 5. Enters data from the electronic medical record and associated documents into the Trauma Registry and various trauma related databases. 6. Facilitates data research and collaborates with the Trauma Program Manager, Trauma Program Analyst,and other trauma team members. 7. May attend trauma rounds and or trauma activations to facilitate data abstraction and performance improvement documentation in the trauma registry. 8. Assists and ensures data download deadlines to state and national regulatory and accreditation organizations to maintain regulatory compliance, accreditation and qualitative comparisions to other trauma centers. 9. Assists with trauma registry upgrades and special projects as requested. 10. Participates in monthly audits and other quality assurance activities to ensure accuracy of trauma registry data. 11. Monitors and reports information technology problems to vendors and manager; make recommendation for improvements. Maintains and demonstrates professional competency, according to state regulations, department policies, procedures and protocols. 12. Assists Trauma Services Team in coordination of all data required for the Trauma Site Surveys. 13. Effectively demonstrates the mission, vision, values and culture of service and operational excellence supported by the medical center. 14. Preserves the confidentiality and security of patient data stored in the trauma registry files. Participates in educational activities of local, state and national Trauma associations, maintains required trauma educational hours. Reviews reference material and current literature relative to Trauma Registry. 15. Researches and solves complex coding problems or registry issues in collaboration with TPM/team. 16. Performs other duties as assigned. ESSENTIAL JOB SPECIFICATIONS: 1. Education: Minimum of high school diploma, Associate Degree in Health Information Management related degree preferred, or minimum of 2-3 years medical experience. Working knowledge of medical terminology, anatomy and physiology or equivalent on-the-job trainingand ICD-9,(ICD 10) coding required preferred. Must attend or have previously attended the American Trauma Society's Trauma Registrar Course or equivalent provided by a state trauma program and the Association of the Advancement of Automotive Medicine's Injury Scaling Course within 12 months of hire. 2. Licensure / Certifications: Certification in medical coding and AIS (Abbreviated Injury Severity Score) and CSTR, (Certified Specialist in Trauma Registry), preferred. 3. Experience: Emergency Medical Services, (EMS), Emergency Department, Operating Room or Critical Care preferred. Previous trauma registry and medical record coding preferred. One to two years experience with databases and statistical analysis preferred. Basic Keyboarding/data entry required and basic Windows base software preferred. 4. Skills and Abilities: Organizational skills with good follow through. Investigative/analytic skills with detail orientation. Professional verbal and written communication skills.