Under the general supervision of the Supervisor-Trauma Quality Assessment, abstracts a variety of trauma related data from patients' medical records and enters into the Trauma Registry for use in quality assessment and research activities. Analyzes registry data; disseminates information in accordance with professional ethics. Preserves confidentiality and security of patient data stored in the registry files.
1 Abstracts a variety of data from patients' medical records and enters into the Trauma Registry.
2 Organizes input and maintains patient computer data to ensure conformance to registry operational standards; preserves the confidentiality and security of patient data stored in the registry files.
3 Assists with data collection for quality assessment/management, special studies and research purposes. Prepares appropriate reports.
4 Performs a variety of functions related to Pennsylvania Trauma Systems Foundation standards compliance and Trauma Center accreditation such as PIPS Participation, research, site survey preparation, and committee work.
5 Compiles data for and prepares regularly scheduled or special reports, analyses and statements.
6 Enters and/or retrieves data from established computer files using knowledge of various computer software applications.
A. Interface with outside agencies
7 Performs database management by maintaining appropriate records, reports, and files as required.
8 Trauma Registry participation in inter-rater should be maintained at multidisciplinary conferences that deal with the review and analysis of trauma registry data.
9 Retains authority, responsibility and accountability for direction and maintenance of the trauma registry and ensuring that it maintains at a minimum, a target of 85% of the cases abstracted within 42 days of discharge.
Post High School Vocational/Specialized Training (Medical secretarial or medical record technician program)
1 - 2 years
Minimum Field of Experience:
Health-related field/allied health
Within one year of hire, the Registrar will complete the Basic Trauma Registry Course and the ATS Trauma Registrar Course. Previous completion of the PTSF Intermediate or Advanced Registrar Course fulfills the above requirements. Other equivalent courses are acceptable based upon objectives.
The Association of the Advancement of Automotive Medicine Injury Scaling Course (Registrars in the role prior to October 1, 2016 must have completed requirements by October 2017).