The Trauma Registrar, utilizing critical thinking, works under the supervision of the Trauma Registry Supervisor. The registrar is responsible for the collection, entry, and maintenance of data for the Trauma Center as required by appropriate regulatory agencies. The registrar will code and enter data into the computerized trauma registry, maintaining confidentiality at all times. It is important to acknowledge that high-quality data begins with high-quality data entry, and it is the trauma registrar who is responsible to perform this task.
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.
- Completes all necessary training for the Trauma Registry as directed by the Trauma Registry Supervisor.
- Ensures comprehensive knowledge of medical terminology and procedures.
- Participates as an integral team member in the preparation for review of the Primary Adult Resource Center.
- Assigns all injuries utilizing the ICD 10 coding system. Completes and verifies for accuracy all data collected.
- Assists with the identification of appropriate cases for inclusion in the trauma registry. Ensures that inclusion criteria for entry in the Trauma Registry as set by the Maryland Institute for Emergency Medical Service Systems (MIEMSS) is followed.
- Ensures compliance with National Trauma Data Bank (NTDB), TQIP, and other State regulatory agencies.
- Performs daily review of medical records for all current in-house patients as well as medical record review of newly discharged patients. Abstracts all the necessary data variables identified for State Trauma Registry ensuring a complete record.
- Reviews radiology reports, discharge summaries and operative notes from EMR to obtain additional detailed information upon patients’ discharge.
- Reviews EMEDS reports to obtain additional PTA information.
- Performs data entry of data points identified after initial chart abstraction.
- Appropriately codes injuries, complications, and procedures with 100% accuracy.
- High School diploma or general education degree required; Associate degree in health- related field preferred.
- Knowledge of anatomy, physiology and medical terminology required.
- AIS/ISS, ICD-10 knowledge preferred.
- Previous Trauma Registry experience – one (1) year preferred.