Facility: Kennestone Hospital

Job Summary:

The Trauma Registry is a complex injury and disease specific database that is integral to the operations of the Trauma Center. Quality Trauma Registry data is critical to the success of a trauma program. The Trauma Registrar is responsible for the management of all components of the Trauma Registry, including data collection, data abstraction, data entry, data retrieval/statistical conversion, and data validation.

The Trauma Registrar Position reports directly to Trauma Program Manager.Key responsibilities of the role include: Data abstraction/entry, database management, inter-rater reliability and data validation, uploading data to state and national Trauma Registries, analysis of data frequency submission reports, monitoring the data base for data integrity and mapping inconsistencies as well as error correction and report writing.

Trauma Registry data is vital to daily operations, process improvement, benchmarking and improving the quality of trauma care delivery. Injury Prevention and Outreach events are developed based on the trauma population captured within the Trauma Registries. Ongoing trauma operations including staffing for trauma clinical care units and Trauma Surgery staff is based on trauma volume and trends. There are regulatory and statutory requirements for Trauma Centers to maintain high quality Trauma Registries. Trauma Registrars must maintain proficiency in anatomy/physiology, in health information technology, trauma specific software, and knowledge of a variety of trauma scoring/scaling methods is essential. The Trauma Registrar must also have knowledge of two independent coding systems: ICD-10-CM/PCS and Injury Severity Coding (AIS).The Trauma Registrar must also learn EMS procedures and terminology, nursing procedures and terminology, radiology terminology, and understand disease processes for capturing comorbid conditions and complications for the registry.They should also have knowledge of ICD-9-CM/PCS for reports and historical data.

Core Responsibilities and Essential Functions:

Data Abstraction/Entry

• Responsible for the abstraction of data from various data sources (electronic health record, Trauma Activation Logs, PI Data sheets, etc.) necessary to complete trauma records within the hospitals’ Trauma Registry
• Identifies records that fall within the Trauma Registry inclusion criteria for hospital, state and national registries.
• Performs data abstraction and entry using established rules and definitions set by the National Trauma Data Bank (NTDB), Trauma Quality Improvement Program (TQIP), State Registry and the hospitals’ data dictionaries
• Informs the Trauma Program Manager (TPM) of all relevant trauma audits filter inconsistencies via monthly Quality Assurance Reports
• Informs the Trauma Program Leadership of all opportunities for improvement in trauma related documentation that may be identified during the data abstraction/entry/validation processes

60%

Data Validation and Inter-rater Reliability

• Analyzes records for quality assurance trauma standards recommended by the Trauma Committee and as stipulated by the American College of Surgeons (ACS) and the Joint Commission (TJC): Data includes all phases of trauma care, i.e., pre-hospital, emergency department and inpatient
• Maintains the highest level of validity to assure accurate program profiling, TQIP, state and internal data reports using based on defined processes
• Completes routine checks of abstracted data for accuracy
• Identifies suspicious or invalid cases, variables and data values and implements corrective action for invalid data

10%

Database Management

• Ensures security and privacy of all Trauma Registry related date in accordance with HIPPA and the Trauma Registry Data Management procedures
• Expands the database management program as needed to meet the needs of the Trauma Program
• Serves as liaison with the registry software vendor and WHS IT department personnel
• Ensures all software program updates are completed as needed
• Ensures data backups are completed at scheduled intervals

5%

Data Extraction and Reporting

• Responsible for the assimilation, extraction, and statistical presentation of all trauma registry data, as required by the ACS, TJC, and as requested by the TPM
• Runs appropriate quality assurance reports and takes corrective action on errors in preparation for each data upload
• Ensures all data uploads to the NTDB, TQIP, and State Trauma Registry are completed on time and documented for reporting
• Produces various other Quality Assurance reports as requested by the TPM
• Ensures Trauma Registry Data Request form is completed and approved prior to the running of and release of Trauma Registry data for any entity other than the TPM, in accordance with the Trauma Registry Data Management procedures

20%

Other Duties

• Attends all Trauma Services meetings are requested
• Responsible for continued professional growth: Must complete 8 continuing education hours annually as required by the ACS. May include:
  • TQIP Conference
  • TQIP Education Opportunities
  • TQIP Annual course (on-line)
  • Hospital, WHS Trauma Center or State trauma education programs
• Participates on at least 1 of the Georgia Trauma Committee for Excellence subcommittees to support regional and state trauma system development

Required Minimum Education:

RHIT (Registered Health Information Technologist) Preferred, with a background in medical terminology and human anatomy. Required

and

A minimum of 8 continuing education hours of trauma related continuing education hours are required annually. Required

and

 20 CEUs during reporting cycle are required for RHIT recertification.

Preferred

Required Minimum License(s) and Certification(s):

Cert Specialist Trauma Registrar 1.00 Preferred

Reg Health Information Tech 2.00 Preferred

Required Minimum Experience:

Minimum 3 years at a state designated American College of Surgeons verified Trauma Center as a Trauma Registrar. Required

or equivalent position Required

Required Minimum Skills:

Proficient in computer entry and data extraction; ICD-10 CM and PCS coding experience.

Database management experience with complex data structure (preferably trauma).

Computer/data entry experience.

Ability to communicate with various members of the healthcare team.

Proficiency with a variety of other computer software products (i.e., MS Office) with accomplished typing and/or data entry skills.

Electronic health record and 3M experience preferred.