Trauma Registrar III

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Work Shift

The Trauma Registrar III is a Trauma Registrar with an RHIT certification and 5‐7 years of trauma registry experience (or 8‐10 years of trauma registry experience in lieu of RHIT) working at a Wellstar Level I or II Trauma Center. This position serves as a coding resource to team members while abstracting and coding records daily. The Trauma Registry is a complex injury and disease specific database that is integral to the operations of the trauma center.

Quality Trauma Registry data must be collected by every trauma center and is critical to the success of a trauma program. The Trauma Registrar is responsible for the management of all components of the Trauma Registry, including data collection, data abstraction, data entry, data retrieval/statistical conversion, and data validation. The Trauma Registrar and Certified Trauma Data Analyst positions report directly to Trauma Program Manager.

Key responsibilities of the role include:
Data abstraction/ entry, database management, inter‐rater reliability and data validation, uploading data to state and national trauma registries, analysis of data frequency submission reports, monitoring the database for data integrity and mapping inconsistencies as well as error correction and report writing. Trauma Registry data is vital to daily operations, process improvement, benchmarking and improving the quality of trauma care delivery.

Injury Prevention and Outreach events are developed based on the trauma population captured within the Trauma Registry. Ongoing trauma operations including staffing for trauma clinical care units and Trauma Surgery staff is based on trauma volume and trends. There are regulatory and statutory requirements for trauma centers to maintain high quality trauma registries. Trauma Registrars must maintain proficiency in anatomy/physiology, in health information technology, trauma specific software, and knowledge of a variety of trauma scoring/scaling methods is essential.

The Trauma Registrar must also have knowledge of two independent coding systems: ICD‐10‐CM/PCS and Injury Severity Coding (AIS). The Trauma Registrar must also learn EMS procedures and terminology, nursing procedures and terminology, radiology terminology, and understand disease processes for capturing comorbid conditions and complications for the registry according to the National Trauma Data Bank (NTDB). They should also have knowledge of ICD‐9‐CM/PCS for reports and historical data.

• Data Abstraction/ Entry
  • Responsible for the abstraction of data from various data sources (electronic health record, Trauma Activation Logs, PI Data sheets, etc.) necessary to complete trauma records within the hospitals Trauma Registry database.
  • Utilizes technical coding principles expertise to accurately assign appropriate ICD‐10‐CM diagnoses and ICD‐10‐PCS procedure codes into trauma database to the greatest specificity.
  • Utilize technical trauma specific coding principles expertise to assign appropriate AIS codes used to calculate the ISS (injury severity score).
  • Identify activation levels and report to Charge Capture for appropriate reimbursement.
  • Identify records that fall within the Trauma Registry inclusion criteria for hospital, state, and national registries.
  • Perform data abstraction and entry using established rules and definitions set by the National Trauma Data Bank (NTDB), Trauma Quality Improvement Program (TQIP), State Registry and the hospitals data dictionaries.
  • Inform the Trauma Program Manager (TPM) of all relevant trauma audits filter inconsistencies via monthly Quality Assurance Reports.
  • Inform the Trauma Program Leadership of all…