Trauma Registrar 1

This position is accountable for the collection completion and verification of the accuracy of all patient data collected for the Trauma Registry data collection system. The Registrar creates and maintains clinical and statistical data AIS coding ICD10CM codes and abstracts various data elements required ensuring consistency and quality in all aspects of the system through data collection. Responsibilities include daily monitoring of trauma admissions for record identification abstracting coding and entering data into the registry.

1. Medical Records and Coding
   1. Identifies the trauma patient medical records. Monitors Emergency Department Admitting department and Trauma Team activation pages daily for trauma admissions.
   2. Performs concurrent/retrospective abstraction from the trauma patients medical record of relevant information required for the Trauma Registry. Takes initiative for finding lost information. This includes contacting pre-hospital care agencies for missing run sheets.
   3. Abstracts core information from patient medical records (including demographic characteristics history of injuries diagnostic procedures and treatment laboratory values and medical complications) and enters select information from trauma patient records to Trauma 1 database.
   4. Accurately assigns codes including diagnoses and procedures using ICD-10-CM and AIS coding. Determines the appropriate sequencing of diseases diagnoses and surgeries.
   5. Maintains patient confidentiality including confidentiality of sensitive hospital performance improvement information.
2. Quality and Performance Improvement
   1. Assists with organization and participates in committees such as: Trauma M&M/Multidisciplinary Peer Review Conference and Trauma Operations meetings.
   2. Maintains continuing education related to trauma registry and PI.
3. Other Duties as Assigned
   1. Performs other duties as assigned or requested.

Experience:
1 year of ICD and/or AIS coding experience. Internship/school training may be substituted for year experience.

Education:
Associate Degree in Health Science or Allied Health related field or Health Information Management

Training:
Successful completion of the Trauma Registry Course is required within the first year of employment.