The Trauma Registrar is responsible for data abstraction and validation of all data entered into the Trauma Registry at St. Luke's Adult Level I Trauma Center. The Trauma Registrar is responsible for the validation and timely submission of all pertinent data to the Pennsylvania Trauma Systems Foundation.
JOB DUTIES AND RESPONSIBILITIES:
- Ensures that the trauma registry includes information on all patients admitted to or seen by the Trauma Service and all Non-Trauma Service patients meeting the trauma registry inclusion criteria.
- Abstracts all data elements from the medical record required for participation in the Pennsylvania Trauma Outcomes Study (PTOS) and the National Trauma Data Bank (NTDB) as well as customized data elements needed to support trauma program functions for all patients accessioned into the trauma registry.
- Ensures accuracy of data abstracted as evidenced by inter-rater reliability scores of greater than 90%.
- Maintains average daily productivity as follows: Inpatient 3-4 charts per hour, Outpatient 8-10 charts per hour.
- Responsible for maintaining up-to-date knowledge of PTSF Standards (registry related), PTOS definitions, collector data definitions, and ICD-9 and other coding definitions.
- Meet or exceed the performance standards below: Demonstrate proficiency in utilizing all work-related applications including Horizon Patient Folder (HPF), Collector, Citrix, Microsoft Office including Word, Outlook, and Excel.
- Meet department productivity standards.
- Not have any level of Corrective Action issued or pending.
- Have available remote network connectivity in their area of residence.
- Demonstrate the ability to work independently and take initiative to problem solve when faced with challenges.
- Works in conjunction with Registry Coordinator(s) to submits data within the mandated six-week time frame for all patients meeting inclusion criteria for the Pennsylvania Trauma Outcome Study and within the quarterly time frame for all patients meeting inclusion criteria for the National Trauma Data Bank (NTDB) and Trauma (TQIP).
- Completes initial data abstraction within forty-eight hours of patient admission.
- Identifies and reports problematic areas related to trauma registry functions and medical record documentation to the Registry Coordinator(s) or Trauma Program Manager in a timely manner.
- Participates in trauma education activities to include attendance at trauma seminars and conferences, and training of personnel in the use of the trauma registry.
- Complies with established chain of command for work-related problems.
- If approved for remote access/work from home, the following are required: Provide a home office (desk, chair, etc.) in a confined and safe work area in the home to achieve confidentiality of patient information and security of equipment to preventdamage, Provide required electrical outlets and pay for required electrical service and other household services such as heating, Establish and keep paid up and in effect a homeowner’s insurance policy at the coder/abstractor’s expense to cover against loss, destruction, theft and/or damage to the Hospital’s equipment. The coder/abstractor, upon request, will timely produce written proof of insurance, such as an insurance binder, Report any injury occurring during at-home work hours immediately to the Director, Network Coding Services. St. Luke’s Hospital shall have reasonable access to the coder/abstractor’s home to conduct accident investigation or job-site evaluation.
- Attendance at meetings as requested. Remote access to meetings will be made available if necessary. Any mandatory meeting will be paid as worked hours excluding travel time to and from the St. Luke's Hospital Coding department.
PHYSICAL AND SENSORY REQUIREMENTS:
Sit up to 8 hours per day, 1-2 hours per day, 1-2 hours at a time. Stand for up to 2 hours per day. Walk 1 hour per day. Consistently lift, carry, and/or push objects up to 20 pounds. Must be able to perceive attributes of an object through touch. Must be able to hear as it relates to normal conversation, and high and low frequencies. Must be able to see as it relates to general, near, far, color and peripheral vision.
EDUCATION:
Associate Degree in Health Information or related field preferred. RHIT, RHIA or CPC preferred.
TRAINING AND EXPERIENCE:
Minimum two years experience in database management is preferred. Previous two to three years experience with use of medical records required. Advanced skills in computer applications such as Microsoft Office, Word, ACCESS and Excel. Use of laptop computer, audiovisual equipment, printers, fax machines is required.
Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!
