Identifies all qualifying cases from the trauma patients brought into the hospital for inclusion in the registry, in accordance with ACS standards; updates previously included cases as needed; assembles chart copies as listed to complete abstractions
Identifies and abstracts data from patient medical records, including demographics, location of injury, and pre-hospital data, for the purpose of statistical reporting, analysis, and inclusion into the trauma registry; collects data and researches missing patient care documentation as needed from multiple sources, including other facilities or agencies.
· Maintains an electronic registry that adheres to reporting requirements and complies with prescribed standards and regulations needed for trauma center accreditation by the ACS Committee.
· Utilizes Abbreviated Injury Scale/Injury Severity Scores (AIS/ISS) and International Classification of Diseases (ICD9) codes to compile indicators and statistics for use by the Trauma Nursing Director, physicians, and other Hospital staff.
· Generates and prepares reports on trauma populations, performs data searches for trauma-related research projects, and provides information that will be used for Performance Improvement activities to facilitate continued education and system improvement.
· Maintains trauma and ambulance logs; reviews the logs for omissions and duplicates; provides log data to other departments (e.g., medical records) as appropriate.
· Prepares and submits periodic data reports of trauma cases and information to the Trauma Nursing Director, Emergency Medical Services (EMS), and/or other Hospital staff/departments as directed; prepares and submits reports to the National Trauma Data Bank, in accordance with ACS guidelines.
· Maintains confidentiality and security of all patient information in compliance with Hospital and federal regulations; maintains quality control of case findings, abstracting, coding, follow-up and data processing.
· Maintains records for continuing Quality Assurance indicators reviewed at periodic meetings.
· Participates in continuing education coursework to stay abreast of new developments in registry data management, regulations, requirements, and trends; assists in updating policies and procedures related to trauma registry activities as assigned.
· Provides general administrative assistance to the Trauma Nurse Director pertaining to the coordination of unit functions.
· Performs other or related duties as assigned.
Note: Supplemental application must be submitted with employment application.
Either Pattern I
Experience: One year performing duties as a Trauma Registrar I in San Joaquin County.
Or Pattern II
Experience: One year performing duties as a trauma registrar in an acute care hospital.
Or Pattern III
Certification: Current certification as a "Certified Trauma Registrar" by the American Trauma Registrars Society Certification Board (ATRSCP).
Trauma registration practices and procedures; basic anatomy and physiology, disease processes, and medical diagnostic procedures; medical terminology applicable to pre-hospital care, emergency room care, and discharge care; general requirements associated with maintaining trauma registries and ensuring compliance with ACS standards; electronic data management and reporting, including the use of standard office software applications and Microsoft Excel; methods of researching and gathering medical information; various types of equipment, instruments and supplies used in an emergency room setting.
Accurately read and interpret handwritten and transcribed documents in a medical record, identify qualifying trauma cases, and abstract/code case information into a trauma registration data base; accurately type at a speed of approximately 40 words per minute; maintain strict confidentiality of information as required by Hospital policies and federal regulations; retrieve and maintain data and information in automated systems and documents; efficiently and effectively utilize standard office computer hardware and software including Microsoft Excel; understand and carry out instructions from medical, nursing and/or other staff; work under pressure and meet critical deadlines; accept changes in work assignments due to shifting priorities; work effectively as a member of a specialized team; communicate effectively, both orally and in writing; maintain cooperative relationships with those encountered during the course of the work.
Mobility - Constant sitting for long periods of time; frequent walking required; occasional pushing/pulling; occasional bending/squatting; occasional stair climbing; Lifting - Frequent lifting required of 5 lbs or less; occasional lifting required of 5 to 25 lbs.; Vision - Constant reading, color perception, eye/hand coordination, depth perception, close up work and field of vision/peripheral; Hearing - Frequent hearing and talking in person and on the telephone; Dexterity - Constant keyboarding/typing, and manipulation of small objects; Emotional/Psychological - Constant concentration; frequent exposure to grief/trauma and emergency situations; frequent decision making; occasional potential for exposure to hazardous materials. Environmental Conditions - Constant work in an indoor environment; occasional loud noises.