Please be aware that proof of ICD-10 coding, college-level Anatomy/Physiology coursework, and college-level Medical Terminology coursework is required.
Job Summary:
The Trauma Registrar is responsible for the collection and abstraction of data base elements following the criteria of inclusion for state and/or national trauma databases
Responsibilities:
The Trauma Registrar, reporting directly to the Trauma Nurse Director/Manager, supports the Southside Medical Center’s organizational requirements for verification as a Level III Trauma Center by the Commonwealth of Virginia and the standards set forth by the American College of Surgeons for maintaining a trauma registry database.
The Trauma Registrar identifies cases for inclusion into the registry data base from various sources including the Master Patient Index, the ED log, and the Trauma Log based upon the guidelines of National Trauma Data Base standard.
Data abstracted will be from various sources including, but not limited, to the electronic medical record, prehospital databases, autopsies reports, and other data sources, either electronic or not that will substantiate the injured patient
The Trauma Registrar will assign ICD-10 CM diagnosis codes for diagnosis, comorbidities and complications and ICD-PCS procedure codes for procedures according to the established and published Official Coding Guidelines.
The Trauma Registrar will assign and verify AIS codes required for severity of illness and probability of survival as established through AAAM manual for AIS coding
Daily chart review and data entry into the Trauma Registry on established patients who meet criteria will be performed.
The Trauma Registrar reports all complications and quality issues to the Trauma PI Coordinator as soon as discovered.
The Trauma Registrar ensures adherence to data management protocols set forth to ensure accurate and timely reporting of data to the organization and regulatory agencies.
The Trauma Registrar assists with performance improvement activities.
Licensure, Certification, or Registration Preferred for Hire:
Certified Abbreviated Injury Scale Specialist (CAISS),
Certified Specialist in Trauma Registries (CSTR),
Certified Professional Coder (CPC);
Certified Coding Specialist (CCS);
Registered Health Information Administrator (RHIA)
Registered Health Information Technician (RHIT)
Paramedic (EMT-P)
Experience Required:
One (1) year work experience in registry data abstraction/coding
Two (2) years experience in medical data abstraction/coding.
Proficiency with MS Office software including email, MS-Word, and MS-Excel
Preferred:
Experience in trauma or surgery registry abstraction/coding
Expert skills using Windows-based software (word processing, spreadsheet, databases)
Abstracting experience using current requirements by state and national regulatory bodies.
Experience with medical terminology and acronyms related to diagnosis, procedures, complications and comorbid conditions
Experience with accurate and timely data entry and verification to maintain high standards of data quality control
Education/training Required:
Work experience may be considered in lieu of credentials not required by law with HR approval. Work experience must be specific to role such as emergency medical services or healthcare related field.
Completion of ICD-10 coding courses
Completion of college-level Anatomy/Physiology courses
Completion of college-level Medical Terminology courses
Preferred:
Requirements for continued employment:
Ongoing data validation scores at the level of 95% accuracy following 12 months of employment and fulfillment of onboarding training requirements. (All levels registrars must maintain)
Certification by the Association for the Advancement of Automotive Medicine as an Abbreviated Injury Scale Specialist (CAISS) within 24months of hire is required for Trauma Registrars.
