Performs functions associated with maintaining the hospital Trauma Registry through data abstraction, data entry assignment of appropriate ICD-10 codes and Abbreviated Injury Scale (AIS) and electronic data submission to Texas Department of State Health Services (DSHS) Trauma Registry and the Southeast Texas Regional Advisory Council (SETRAC) Regional Trauma Registry and National Trauma Data Bank (NTDB).
- Consistently supports the hospital’s Spirit of Serving Standards, in line with the Mission, Vision and Values of St. Joseph Medical Center.
- Follows the St. Joseph Medical Center’s Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
- Promotes a culture of safety for patients and employees through proper identification, proper reporting, documentation and prevention of medical errors in a non-punitive environment.
- Identify trauma patients based on ICD-10 codes for S00-T99, T07, T14, T20-T28, T30-T32 and T79.A1-T79.A9 for chart abstraction using the ER Trauma report and Transfer Center Log.
- Perform daily chart abstraction on trauma patients and enters data into trauma base which include patient demographic information, dates of service, diagnoses and procedural information.
- Accurately assign injury codes and procedure codes using ICD-10 coding.
- Order trauma charts for review and completion.
- Maintain an up to date trauma registry with quarterly uploads to DSHS State registry, SETRAC regional trauma registry and yearly to the NTDB.
- Run reports as directed by Trauma Program Manager.
10 Prepare reports on all drowning for submission to DSHS State registry.
- Assist in the preparation for licensing and regulatory surveys for Trauma Designation.
- Assist in the planning and implementation of injury prevention program activities and community outreach education activities.
- Provides secretarial support in typing, word processing, photocopying in trauma-related committees directed by the Trauma Program Manager.
- Supportive of the compliance program set forth by SJMC and demonstrated by:
- Upholds the Code of Ethics and Corporate Compliance.
- Adheres to and helps to enforce all compliance policies relevant to his/her area.
- Assures timely compliance education as requested by the Compliance Officer and/or through corporate initiatives.
- Sets an example to all staff in their daily activities.
- Other duties as assigned.
- ICD-10, AIS and ISS coding experience preferred
- Previous medical records experience preferred
- Knowledge of anatomy and medical terminology;
- American Trauma Society (ATS) Basic Trauma Registrar Core Course preferred upon hire; if does not have will complete within one year.
- Certification Abbreviated Injury Scaling (CAISS) preferred upon hire; if does not have will complete within one year.
EDUCATION & TRAINING:
- High School Diploma or equivalent
- Completion of Association for the Advancement Automotive Medicine (AAAM) Abbreviated Injury Scaling (AIS) course.
- Computer literate.
- Proficient with Microsoft Office, including Excel Spreadsheet.
- Typing and office management skills which include organization necessary to perform multiple tasks.
- Ability to accurately take notes and transcribe meeting minutes.
- Interpersonal skills with employees, physicians and visitors.