Job Summary

This position develops, implements and participates in trauma registry data entry practices that ensure accurate data, timely data entry and timely reports to meet criteria for Level I-IV Trauma Center requirements. Is responsible for the daily collection and management of the trauma registry database. Acts as a member of the multi-disciplinary trauma team to support patient quality and performance improvement initiatives and to submit data to state and national entities. The primary role is the collection, abstraction and entering of defined data elements for all trauma patients admitted to or evaluated by the trauma service as well as those meeting trauma registry inclusion criteria.

Essential Functions

• For all seriously injured trauma victims, collects all required information, reviews multiple medical records, and abstracts basic patient demographics, clinical procedures, clinical and diagnostic results. Enters abstracts and data, maintains, retrieves, and analyzes records related to the trauma patient's history, diagnosis, therapy, and outcome.

• Using scaling and scoring tools such as ICD-10-CM, Trauma Score, Revised Trauma Score, Abbreviated Injury Score, Injury Severity Score, TRISS and the Abbreviated Injury Scale (AIS) developed by the Association for the Advancement of Automotive Medicine (AAAM), codes injuries and procedures for the database as required for clinical care, research, benchmarking and accreditation; accurately codes each, using the AIS Abbreviated Injury Scale, ICD-10 and CPT coding tools. Ensures the hospital remains compliant with all standards as they relate to the American College of Surgeons (ACS), National Trauma Data Bank (NTDB), Trauma Quality Improvement Program (TQIP) and trauma center designation and accreditation.

• Maintains the Trauma Registry database in compliance with state regulations and certification requirements. Assists team with documentation and management of the registry database as it relates to clinical research, benchmarking and accreditation.

• Develops and produces timely information as requested by administration and/or the American College of Surgeons for accreditation/re-verification/re-designation purposes and performs timely data submission to national and state agencies for same purposes.

• Works as an integral part of the hospital and trauma quality and performance improvement process by identifying opportunities for improvement at the level of training/knowledge/experience.

• Assists with developing and/or running standard reports at the direction of supervisor.

• Assists in training new staff at the direction of supervisor.

Minimum Qualifications

Requires a level of education equivalent to that of a Registered Health Information Technologist (RHIT) or certified coder, including advanced education in medical terminology, anatomy and physiology.

Certification as a Certified Specialist Trauma Registry (CSTR).

Must have a level of experience and ability in coding, abstracting and data management as normally acquired over four or more years of full-time clinical and/or experience in a coding or clinical data management position. Requires the ability to interpret and comprehend information contained within the patients medical record and to find all ancillary information required by the Trauma Registry. Requires the ability to abstract registry data from the patients medical/health record using the above standard setters with regard to abstracting and coding procedures. Must have excellent organizational, written and verbal communication skills, and the ability to prioritize multiple work projects and tasks. Exceptional data entry and data management skill sets are required. Must be able to work effectively with common office computer software, the Trauma Registry software, the electronic medical records system and databases, spreadsheet and graphical programs.

Preferred Qualifications

Associates or Bachelors degree.Licensed medical professional paramedic, RN, or LPN.

Additional related education and/or experience preferred.