Trauma Registrar 1

Job Description

This position 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 coding, ICD10CM codes and abstracts various data elements required ensuring consistency and quality in all aspects of the system through data collection. Responsibilities include daily monitoring of trauma admissions for record identification, abstracting, coding and entering data into the registry. Retrieves registry data for quality improvement and research to provide accurate statistical trauma data. The Trauma Registrar is responsible for coordination of billing and reimbursement data with billing office. This is not necessarily an exhaustive list of all responsibilities, skills, duties, requirements, efforts, or working conditions associated with the job. While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different tasks be performed when circumstances change (e g., emergencies, changes in personnel, workload, rush jobs, or technological development).

• 1 year of ICD and/or AIS coding experience. Internship/school training may be substituted for year experience.
• Associate's Degree
• Successful completion of the Trauma Registry Course is required within the first year of employment.

1. Medical Records and Coding

• a. Identifies the trauma patient medical records. Monitors Emergency Department, Admitting department, and Trauma Team activation pages on a daily basis for trauma admissions.
• b. Performs concurrent/retrospective abstraction from the trauma patients medical record of relevant information required for the Trauma Registry. Takes initiative for finding lost information. This includes contacting pre-hospital care agencies for missing run sheets.
• c. Abstracts core information from patient medical records (including demographic characteristics, history of injuries, diagnostic procedures and treatment, laboratory values and medical complications) and enters select information from trauma patient records to Trauma 1 database.
• d. Accurately assigns codes including diagnoses and procedures using ICD-10-CM and CPT4 guidelines. Determines the appropriate sequencing of diseases, diagnoses, and surgeries. Coordinates all patient charges to assure appropriate billing and reimbursement.

2. Quality and Performance Improvement

• a. Assists with organization and participates in committees such as: Trauma M&M Conference and Trauma Operations meetings.
• b. Maintains continuing education related to trauma registry and PI.
• 3. Other Duties as Assigned

3. Performs other duties as assigned or requested.

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