This job supports the VCU Health Trauma Program and organizational requirements for verification as a Level 1 Trauma Center by the Commonwealth of Virginia and the American College of Surgeons Committee on Trauma by maintaining a unique database called the Trauma Registry. This includes identification of cases for inclusion into the trauma registry database, abstraction of data from various sources including the electronic medical record, prehospital databases, and other data sources. This job assigns ICD 10 diagnosis codes and Abbreviated Injury (AIS) Scores to injuries, procedures, comorbidities and complications according to ICD-10 and Abbreviate Injury Scoring methodologies and coding rules. This job performs on-going daily chart reviews on all injured patients and enters data into the Trauma Registry. This job reports complications and quality issues to the Trauma Registry Operations Coordinator or Trauma Program Manager. This job ensures adherence to data management protocols set forth to ensure accurate and timely reporting of data to the Organization and regulatory agencies. This job also assists with performance improvement activities and information requests.
Licensure, Certification, or Registration Requirements for Hire: Certification by the Association for the Advancement of Automotive Medicine in Abbreviated Injury Scoring (CAISS) or Certified Specialist in Trauma Registry (CSTR)
Licensure, Certification, or Registration Requirements for continued employment: Certified Specialist in Trauma Registry (CSTR) must be obtained within 6 months of hire Certification by the Association for the Advancement of Automotive Medicine in Abbreviated Injury Scoring (CAISS)
Experience REQUIRED:
Three (3) years of work experience in trauma registries or five (5) years experience in medical data abstraction/coding
Abstracting experience using current requirements by state and national regulatory bodies
Expert proficiency with Windows-based and MS Office software including email, MS-Word, and MS-Excel and databases
Experience PREFERRED:
One year of experience in trauma registry abstraction in an academic medical center Expert at ICD-10, Abbreviated Injury and Injury Severity Scoring
Experience analyzing requests for data and creating moderate to complex reports from the registry
Excellent investigative/analytical skills with detail orientation
Understanding of medical terminology and acronyms related to accurate identification and coding of injuries and procedures
Experience analyzing data for accuracy and validating data for submission to national databases in a timely manner
Familiarity with information technology hardware and software in a local and wide area network environment
Education/training REQUIRED:
(Note: work experience may be considered in lieu of credentials not required by law with HR approval. Work experience must be specific to role)
Associates Degree in a healthcare-related field or in medical records coding including at least two semesters of human anatomy/physiology and medical terminology from an accredited program
Education/training PREFERRED: Completion of ICD-10 coding courses
Additional position requirements:
Must be willing and able to work evenings and weekends when necessary based on case volumes and state/national verification site surveys.
Physical Requirements (includes use of assistance devices as appropriate):
Physical: Lifting less than 20 lbs.
Activities: Prolonged sitting
Repetitive motion: Keyboarding, Mouse
Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking
Emotional: Steady pace, Frequent and intense customer interactions, Noisy environment, Able to adapt to frequent change
Essential Function
Performance Expectations: Abstraction/Coding
Identifies reportable injuries. Reviews and abstracts information from patient medical records (VCUHS, prehospital, outside agencies) including demographic characteristics, history of injury, diagnostic procedures, final diagnosis, comorbidities, treatments, complications and outcomes. Independently researches and solves highly complex coding problems. Accurately code injuries to ICD-10 and Abbreviated Injury Scoring and enter into database (trauma registry). Maintains minimum 95% accuracy rate per abstract. An accurate abstract is defined as a patient registry file/abstract with no errors. Maintains a concurrent process of data abstraction and coding. Concurrent is defined as at least 90% of assigned cases are opened within 48 hours of assignment and at least 50% of assigned cases are closed within 2 weeks of discharge and 75% are closed within 30 days of discharge. Abstracts other required information in compliance with standards set by the American College of Surgeons, the Virginia State Trauma Registry, guidelines set by the VCUHS or VCU Trauma Center and departmental standards. Obtains ongoing follow-up information to include medical status from patient medical records. Responsible for orienting new staff Serves as a resource to staff regarding abstracting, coding, departmental procedures, the trauma performance improvement process.
Performance Expectation: Reporting/Compliance
Ensures the National Trauma Data Standards/Dictionary and Virginia Trauma Registry Standards are met. Maintains data collection. Provides required data to be submitted to the organization, state or national agencies on a monthly and quarterly basis. EACH abstract must pass local, regional and national edits before submission. Participates as a key member in the trauma performance improvement process by attending morning report, weekly and monthly Performance Improvement (PI) meetings and analyzes complications and performance improvement events for inclusion in the registry. Participates in basic and advanced data quality control activities and identifies opportunities for improvement. Develops complex and custom reports upon the request of the Trauma Registry Operations Coordinator/Trauma Program Manager. Preserves the confidentiality and security of patient data. Organizes, enters and maintains patient computer data to ensure conformance to trauma registry operational standard and to meet the needs of the users of registry data. Assists in achieving the goals of the Trauma Program by assisting with state and national accreditations. Assists in the preparation and submission of data to the National Trauma Data Bank and the Virginia State Trauma Registry. Assists with and leads special projects as required.
Performance Expectation: Continuing Education/Training
Maintains CAISS certification. Maintains CTSR certification. Participates in an educational activity each year of local, state or national level pertaining to registrar education. Review reference material and current literature relative to trauma registry/trauma care. Completes 24 hours of trauma registry, coding or trauma related continuing education over a three year period.
Performance Expectation: Research
Participates in research activities following applicable IRB rules, Federal (e.g. HIPPA) and state regulations as required. Assists and collaborates with the Trauma Registry Operations Coordinator/Trauma Program Manager or other researchers on trauma-related studies and research projects.
Performance Expectation: Miscellaneous Responsibilities
Performs other duties as assigned and/or participates in special projects in order to support the mission of VCUHS and the Department. Provides assistance to team members. Accepts alternate assignments, as required, graciously.
EEO Employer/Disabled/Protected Veteran
