This job is responsible for the identification of trauma patients meeting registry inclusion criteria, abstracting clinical and outcomes data from the medical record, coding diagnoses, procedures, and injuries utilizing ICD-9 coding, AIS coding, E-Codes, and entering data into the Trauma Registry per National Standards and State Standards/State Trauma Regulations published by the American College of Surgeons (ACS), National Trauma Data Bank (NTDB) and SC Department of Health and Environmental Control (DHEC). Performs data analysis on Trauma Registry data for monitoring data quality and performs data analysis and writes reports to support the activities of the Trauma Program such as performance improvement, research, administrative and medical staff meetings, injury prevention, and Trauma Center Designation/Verification process.
Maintains professional development and current in coding principles. Maintains current knowledge of and complies with National standards published by the ACS, State Standards published by DHEC and State Trauma Regulations. Maintains registry within the standards and dataset of NTDB, State Trauma Registry Data Dictionary, and PHR Trauma Program.
Accurately identifies patients meeting Trauma Registry inclusion criteria per SC Trauma Registry Data Dictionary, NTDB and ACS standards for inclusion into the Trauma Registry.
Accurately abstracts clinical data from pre-hospital EMS database and the in-patient medical record including demographics, co-morbidities, diagnoses, injuries, ED data, operations, procedures, complications, outcomes, performance improvement, and financial data per SC Trauma Registry Data Dictionary, NTDB and ACS standards, and PHR Trauma Program.
Accurately codes procedures, diagnoses, and injuries using ICD-9 coding, AIS injury coding, E-codes and other appropriate coding schemes, and accurately enters into Trauma Database within departmental guidelines.
Participates in performance improvement monitoring by gathering data on performance metrics, identifying and reporting complications, and performing analysis of registry data in support of clinical process improvement initiatives. Prepares reports pertinent to Trauma performance improvement and reports issues and trends identified to PI Coordinator and TPM.
Prepares, processes and submits Trauma Registry records to State Trauma Registry quarterly per State Trauma Regulations and annually to the National Trauma Data Bank within established timeframe. Ensures compliance of registry with Prisma Health HIPAA regulations.
Responsible for report writing from the Trauma Registry Database for information requests by trauma administration, physicians, other PHR departments, and outside entities to support coding, billing, trauma research, injury prevention, performance improvement, Trauma Center Designation/Verification process, and other activities of the Trauma Program. Ensures compliance with Palmetto Health HIPPA and IRB research policies.
Performa data analysis and data validation on Trauma Registry Data on a routine basis for data quality and errors and omissions to maintain registry integrity.
Attends and participates in Multi-disciplinary Trauma Patient Care Conference, Multi-disciplinary Trauma Committee, and Trauma Association of South Carolina. Participates at the State level in all activities involving Trauma Registry.
Independently works with Trauma Registry software vendor and PHR information technology on NTDB and State data submissions, upgrades, data imports, and all enhancements involving Trauma Registry.
Education: Bachelor's degree in Health Information Management or related field OR an equivalent combination of relevant education and/or experience.
Experience: 2 years experience in in-patient medical record coding
Licensure, Registry or Certification Required: RHIT, RHIA, CCS, or CSTR (Certified Specialist in Trauma Registry) preferred or eligible. Requires certification within 2 years and AAMA coding certificate within 1 year.
Special Training: Extensive knowledge of ICD-9 coding, AIS coding, E-codes, anatomy, physiology, medical terminology and disease processes. Must be computer literate and be proficient in keyboarding, spreadsheets, word processing, and databases. Requires ability to analyze and report registry data to support the activities of the Trauma Program. Must have ability to work independently and have a strong aptitude for detail.