Trauma Registrar / Trauma Dept / Full Time / 40 Hrs per wk / Days - Terre Haute Regional Hospital - Terre Haute, IN

The Trauma Registrar is responsible for the collection, completion, and verification of the accuracy of all patient data collected from Terre Haute Regional Hospital and the Trauma Registry data collection system. This position is crucial to the implementation of quality assurance and improvement issues by serving as the foundation of the Trauma Program. The Registrar creates and maintains clinical and statistical data, AIS coding, ICD-9-CM and ICD-10-CM codes, and abstracts various data elements as required by the American College of Surgeons, the National Trauma Data Bank, Trauma Quality Improvement Program, the Indiana State Trauma Registry, and Terre Haute Regional Hospital. The Registrar will provide data and statistics from the trauma registry to the Trauma Program Manager to base injury prevention and community education upon. As time allows, the Registrar will assist the Trauma Program Manager with trauma outreach efforts. This position is held accountable by the standards of the trauma registry and reports directly to the Trauma Program Manager.

Behavioral Characteristics:

• Enthusiastic, positive attitude, dependable, reliable, conscientious, attention to detail, tactful, flexible, and cooperative

• Demonstrates behaviors that are relative to the HCA Mission and Values Statement: “We act with absolute honesty, integrity, and fairness in the way we conduct our business and the way we live our lives.”

• Demonstrates critical thinking skills, strong analytical skills, and excellent communication skills

• Self-directed with initiative to function independently as needed

• Possesses excellent organizational skills with ability to prioritize requests and assignments

Position Responsibilities:

• Data Collection

o Identifies patients to input into the trauma registry per trauma program inclusion/exclusion criteria.

o Collects and analyzes data on trauma patients that is detailed, reliable, and readily accessible; concurrent collection through chart review and staff interview is preferred.

o Performs basic data collection of demographics, and coding of clinical and follow-up data from all sources into trauma registry database. Interacts with physicians, nurses, and other members of the trauma team and trauma patients to perform trauma registry functions. Will keep registry current within 60 days of patient discharge.

o Enters data daily into the trauma registry, analyzing patient records for data entry points as well as looking for possible quality/safety issues.

o Abstracts, assembles, enters, and codes clinical data with 95% accuracy into computer database by using the Association for the Advancement of Automotive Medicine Abbreviated Injury Scale (AIS), current ICD9/ICD10 coding, and the Registry Users Operations and Standards Manual.

• Data Reporting

o Submits clean data to the Indiana State Trauma Registry quarterly, and the National Trauma Data Bank yearly as requested. Provides registry reports to hospital personnel as requested.

o Produces reports from trauma data base in Microsoft Word, Excel, or Power Point as requested.

o Participates in quality assurance and improvement activities to ensure accuracy of data collection and timely submission of data according to Indiana State Trauma Registry, National Trauma Data Bank, Trauma Quality Improvement Program, and the American College of Surgeons Optimal Guidelines for Trauma Centers.

o Presents requested trauma registry data at meetings such as Clinical Monitoring Committee (CMC) and Trauma Operational Process Performance Committee (TOPP) meetings as requested.

• Data Validation

o Participates in process of validation of registry data.

• Data Security/Patient Confidentiality

o Maintains patient confidentiality including confidentiality of sensitive hospital performance improvement information.

• Other

o Resolves routine coding issues/problems and appropriately seeks assistance from Trauma Program Manager for the more difficult ones.

o Participates in Trauma Performance Improvement and ACS Committee meetings and educational conferences in order to maintain and expand Trauma Registry knowledge base.

o Participates in internal and community outreach education on injury prevention, trauma systems, and trauma data.

o Assists with other department functions as assigned.

Qualifications

Essential educational/licensure, skills and experience:

• BS or BA degree

• Excellent typing skills, computer literacy and proficiency in Microsoft Word, Excel, and Power Point

• Critical thinking skills and orientation to detail

• Above average communication skills in all forms

• Ability to multitask with prioritizing and meeting deadlines

• Must successfully complete or have previously completed the following 2 courses within 12 months of in-hire:

o The American Trauma Society’s Trauma Registry Course or equivalent provided by a state trauma program

o The Association of the Advancement of Automotive Medicine’s Injury Scaling Course

o Must obtain trauma registry certification; Certification Specialist in Trauma Registries (CSTR) through the American Trauma Society’s Registrar Certifcation Board within 2 years, or 4160 hours of hire.

Valued but not required educational/licensure, skills and experience:

• Previous experience as trauma registrar

• Knowledge of various software packages, data entry skills, knowledge of basic anatomy, ICD-10-CM coding, E-codes, Injury Severity Scoring, and Probability of Survivability

• An understanding of quality assurance and performance improvement

• Experience with data analysis and report writing

• At least one (1) year experience as Patient Care Assistant, Administrative Assistant, or Medical/Clerical Experience, preferably in a healthcare setting

• Previous Medical Records coding experience

• Current CSTR (Certified Specialist in Trauma Registers) certification