THE TRAUMA REGISTRAR IS RESPONSIBLE TO MAINTAIN EFFICIENT OPERATION OF THE TRAUMA PATIENT REGISTRY. tHE REGISTRAR ENSURES CONSISTENCY AND QUALITY IN the TRAUMA PATIENT DATA COLLECTION SYSTEM MAINTAINING COMPLIANCE WITH THE PENNSYLVANIA TRAUMA SYSTEMS FOUNDATION REQUESTS FOR DATA.
*Complies with PENN HIGHLANDS DUBOIS policies and procedures, accreditation agency requirements, and federal, state or local law and regulations
Demonstrates competency in the Trauma Registrar role by:
Accurately identifies trauma patients by monitoring daily ED and admission patient types.
Manages patients in the database
Accurately and efficiently abstracts from the trauma patient medical record relevant information required for the hospital registry and the Pennsylvania Trauma Outcome Study, including selection and coding of diagnoses and procedures using ICD10-CM, and calculation of trauma and Injury Severity Scores.
Ensure that all PTOS information is accurate, complete, and submitted within the time frames established by PTOS protocol.
Accurately maintain the statistical database, generate routine monthly reports, and respond to special requests for statistical information.
Accurately maintain the computerized registry system, which includes keying data, making additions, and making corrections as necessary.
Retrieve information from the database upon request of Trauma Services or other appropriate personnel.
Maintain communications with the state Trauma Registrar and/or PTOS analysts for purposes of clarifying information or respond to requests for clarification of information. Document and disseminate information as appropriate.
Perform additional trauma patient medical record abstracting or audit activities for quality assurance, research, education, or for the purpose of identifying and addressing documentation deficiencies. Work with the Trauma Nurse Coordinator and Trauma Program Manager to collect, organize, and disseminate results. Engage in follow-up activity as appropriate
Attend and participate in Trauma QI activities.
Maintain confidentiality of patient information and follow hospital policies relating to security of patient information.
Must complete a minimum of 8 hours of external or internally designated Trauma Registry continuing education. Maintain and expand current knowledge base through attendance at appropriate in-services. Provide documentation to the Trauma Program Manager of the completion of these outlined continuing education programs.
Perform related responsibilities as requested by the Trauma Program Manager.
Participates in the development of new staff as evidenced by but not limited to:
Actively participates in the orientation including cultural and social integration of new staff.
Demonstrates personal accountability as evidenced by but not limited to:
Achieves educational credits to meet hospital requirements.
Shares information obtained at educational conferences to staff members.
Participates in implementing department initiatives.
Conducts self in a professional manner in dress, actions, and interpersonal communication.
Ensures environment of safety for patients, significant others, and coworkers.
Informs Service Line Director/Trauma Program Manager of situations as appropriate
Demonstrates effective problem solving skills related to the registrar role.
General duties as directed
- Graduate of an accredited record technician program with 2-3 years of coding and/or abstracting experience; or minimum Associate’s Degree in a health related field 2-3 years of coding and/or abstracting experience required
- Demonstrated knowledge of medical record content, medical terminology, anatomy and physiology is required.
- Prior experience in ICD-10 coding is required.
- Completion of the Basic Trauma Registrar Course and the Association of the Advancement of Automobile Medical Injury Scaling Course within one year of hire.
- Abbreviated Injury Scoring (AIS) is desirable. Demonstrated experience in computer data entry, databases, and data retrieval is desirable.