Trauma Registrar

Summary

SUMMARY : The Trauma Registrar is a member of the trauma program that will be responsible for the collection and analysis of data including, although not limited to : Trauma Registry, NTDB, TQIP and hospital quality data.

including data collection on defined trauma patients, entry of data into the registry, assuring accuracy of data, correcting deficiency in data, updating registry, and abstracting data from registry for reporting and trend analysis in accordance with the regulatory requirements that support the Trauma Departments Performance Improvement and Patient Safety (PIPS) program.

The data abstraction and analysis aids in performance improvement, public health, injury prevention, outcomes measurement and research.

This position serves to enhance trauma performance improvement, patient safety initiative and research and reports to the Trauma Program Manager of Trauma Services.

The Trauma Registry contains patient care data from the following phases of care : Pre-hospital, trauma room and hospital course.

The incumbent evidences confidentiality in the handling of all trauma registry matters, and is concerned with the improvement of Trauma Services within AHS.

Performs related duties as required.

DUTIES & ESSENTIAL JOB FUNCTIONS : NOTE : The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level.

Not all duties listed are necessarily performed by each individual in the classification.

1. Assigns and scores all injuries with appropriate coding; completes final retrospective injury coding to include ICD-10 CM and Association for the Advancement of Automotive Medicine (AAAM)-Abbreviated Injury Scoring to calculate Injury Severity Scores and probability of survival;

and external cause injury-coding to track and report mechanisms of injury. Compliance with NTDB inclusion criteria and data element definitions.

Demonstrates knowledge of Alameda County EMS-A trauma center designation criteria. Demonstrates knowledge of ACS Verification requirements.

2. Assist in compiling data for research project and with the design of Trauma One Queries, validation, analysis and participate in other scholarly activities (i.

e. ATLS) as directed by Trauma Program Manager, Trauma Medical Director. Writes reports using the trauma registry to support trauma research, performance improvement, best practices and injury prevention.

Utilizing registry software to perform validation of performance improvement filters that are captured and submitted to the Trauma Quality Improvement (TQIP).

Participate in bi-annual benchmark.

3. Validates 10% of cases by participating in departmental inter-rater-reliability activities on a monthly basis, running monthly departmental validation reports, and monthly National Databank validation reports.

4. Has primary responsibility for maintaining the trauma registry database; identifies patients to be entered into the Trauma Registry Database.

5. Attends departmental, local, regional, and state trauma meetings and committees as required by Alameda County and the American College of Surgeons.

6. Participates in concurrent and retrospective chart abstracting and data entry of Trauma patients into Trauma Registry Database.

7. Prepares audited charts for review in a timely manner and support the Performance Improvement and Patient Safety process (PIPs) committee meetings with any needed data or reports or focused audits.

8. Responsibility for obtaining, abstracting, correcting, and entering appropriate patient data both concurrently and retrospectively along with assigning Injury Severity Scores to all trauma patients at AHS in order to maintain an accurate and concurrent trauma patient data base for the trauma program County and State downloads, Update / download all EMS reports, Assist with the American College of Surgeons Trauma Survey process.

This will include assisting with the completion of the pre-review questionnaire, planning / coordination of the site visit, chart preparation, and assisting as needed through the survey process are recorded in the Trauma One data base.

9. Utilizes other data bases including Quality Department data to supplement and complement data collected from the medical record.

MINIMUM QUALIFICATIONS :

Education : Associate's Degree; Bachelor's degree or equivalent experience preferred.

Minimum Experience : Two- three years experience abstracting data from medical records required. Must include one year of collecting and entering data into a registry.

Required Certification / Licenses : Current incumbents must possess at least one of the following certifications : Trauma Registry Course by American Trauma Society must be obtained within one year of start date, Certified Registrar by American Trauma Society, RHIT (Registered Health Information Technician), RHIA (Registered Health Information Administrator) or CSTR (Certified Specialist in Trauma Registry) and CAISS Certification for Abbreviated Injury Scale (AIS) specialists.

If new hire does not possess a Certified Specialist in Trauma Registry (CSTR) by American Trauma Society, it must be obtained within one year of the start date and 32 contact hours of continuing education (CE) related to Trauma Registry practice must be obtained for recertification every 4 years.

If new hire does not possess a CAISS Certification for Abbreviated Injury Scale Specialist by AAAM, it must be obtained with one year of the start date and renew every 5 years.

Complete basic Anatomy Course of new hire within one year of hire. ACS Requirement : each Trauma Registrar must accrue at least 24 hours of trauma-related CE during the verification cycle every 3 years.