Trauma Registrar- Full-Time Day Shift- Hybrid

Core Responsibilities and Essential Functions

Data Abstraction/Entry

• Responsible for the abstraction of data from various data sources (electronic health record, Trauma Activation Logs, PI Data sheets, etc.) necessary to complete trauma records within the hospitals’ Trauma Registry.
• Utilizes technical coding principles expertise to assign appropriate ICD-10CM diagnoses and ICD-IOPCS procedure codes into trauma database.
• Utilizes technical trauma specific coding principles expertise to assign appropriate AIS codes used to calculate the ISS (injury severity score).
• Identifies activation levels and report to Charge Capture for appropriate reimbursement.
• Identifies records that fall within the Trauma Registry inclusion criteria for hospital, state and national registries.
• Performs data abstraction and entry using established rules and definitions set by the National Trauma Data Bank (NTDB), Trauma Quality Improvement Program (TQIP), State Registry and the hospitals’ data dictionaries.
• Informs the Trauma Program Manager (TPM) of all relevant trauma audits filter inconsistencies via monthly Quality Assurance Reports.
• Informs the Trauma Program Leadership of all opportunities for improvement in trauma related documentation that may be identified during the data abstraction/entry/validation processes.
• Meets productivity standards.
• Queries physicians when needed to further clarify code assignments.

Data Validation and Inter-rater Reliability

• Analyzes records for quality assurance trauma standards recommended by the Trauma Committee and as stipulated by the American College of Surgeons (ACS) and the Joint Commission (TJC): Data includes all phases of trauma care, i.e., pre-hospital, emergency department and inpatient.
• Maintains the highest level of validity to assure accurate program profiling, TQIP, state and internal data reports using based on defined processes.
• Completes routine checks of abstracted data for accuracy and maintains an accuracy rate of 95%. Identifies suspicious or invalid cases, variables and data values, implements corrective action for invalid data, and reports findings to the Certified Trauma Data Analyst and TPM for further review.

Database Management

• Ensures security and privacy of all Trauma Registry related date in accordance with HIPPA and the Trauma Registry Data Management procedures.
• Ensures data is collected in compliance with National Trauma Data Standards (NTDS).
• Expands the database management program as needed to meet the needs of the Trauma Program.
• Serves as liaison with the registry software vendor and WHS IT department personnel.
• Ensures all software program updates are completed as needed.
• Ensures data backups are completed at scheduled intervals.

Data Extraction and Reporting

• Responsible for the assimilation, extraction, and statistical presentation of all trauma registry data, as required by the ACS, TJC, and as requested by the TPM.
• Runs appropriate quality assurance reports and takes corrective action on errors in preparation for each data upload.
• Ensures all data uploads to the NTDB, TQIP, and State Trauma Registry are completed on time and documented for reporting.
• Produces various other Quality Assurance reports as requested by the TPM.
• Ensures Trauma Registry Data Request form is completed and approved prior to the running of and release of Trauma Registry data for any entity other than the TPM, in accordance with the Trauma Registry Data Management procedures.

Other Duties

• Attends all Trauma Services meetings as requested.
• Participates in the Georgia Committee of Trauma Excellence (GCTE) Trauma Registry Subcommittee.
• Responsible for continued professional growth: must complete 8 continuing education hours annually as required by the ACS. May include: TQIP Conference, TQIP Education Opportunities, TQIP Annual Course (on-line), Hospital, WHS Trauma Center or state trauma education programs.
• Helps to support regional and state trauma system development.