Trauma Program Registrar II - 40 Hours - Days

GENERAL SUMMARY:

The Trauma Program Registrar II is located at a Level I Trauma Center and 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 scoring, ICD10CM and PCS coding. Abstracts various data elements required ensuring consistency and quality in all aspects of the system through data collection.

 The trauma registrar also ensures compliance with established coding guidelines. Interact with state and regional regulatory agencies providing required data to ensure the accreditation of the hospital’s designation as a Verified Level 1 Trauma Center. This role will reflect the most recent criteria outlined in the current American College of Surgeons (ACS) document “Resource for the Optimal Care of the Injured Patient” with respect to registrar, regulations and accreditation guidelines.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

1. Monitors Emergency Department, admitting department, Transfer Reports and Trauma Team activations daily to Identify trauma patients that meet registry criteria.

2. Identifies all diagnostic, operative, procedural, and other pertinent patient stay data from Henry Ford Health System databases by thoroughly reviewing entire patient medical records, including histories and physicals, operative reports, pathology reports, therapy notes nursing notes and discharge summary.

 3. Performs concurrent/retrospective abstraction from outside organizations that include pre-hospital Emergency Medical Services reports and Medical Examiner Offices for autopsy reports.

 4. Compiles all trauma registry data as required by ACS and requested by the Trauma Medical Director and/or Trauma Program Manager with all relevant trauma audit filter inconsistencies in monthly reports. Produce various other QI reports as requested by the Trauma Committee and present information at quarterly Institutional meetings

5. Accurately assigns codes including diagnoses and procedures using ICD-10-CM and ICD-10-PCS guidelines. Determines the appropriate sequencing of diseases, diagnoses, and surgeries. Identifies appropriate Abbreviated Injury Scale (AIS) score. TITLE: Trauma Program Registrar II F01796 Page: 2 of 3

6. Maintains the computerized Trauma Registry system, which includes keeping data updated and making additions/corrections, downloading and sending data to the National Trauma Data Bank. Works with software vendor and hospital IT department for updates to the registry to maintain current data element collection and to correct problems.

 7. Prepares and tabulates monthly and annual statistics. Prepares reports from the Trauma registry data and presentations of these statistics for quality improvement, research, to monitor new trends in trauma care and for Trauma Peer Review M&M Committee.

8. Participates in various research projects as needed in the department through data collection methods to extract vital information pertaining to the trauma program related to objectives and reporting requirements.

9. Maintains a working knowledge of both the national and local state trauma data dictionaries.

10.Maintains continuing education related to trauma registry and PI.

11.Verifies completeness of medical record within electronic medical record, reporting any discrepancies to supervisor.

 12.Interacts with medical staff including residents, fellows and surgeons throughout the hospital for clarification of documentation.

13.Perform other related duties as assigned.