Facility: 55 Whitcher Street

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 must be collected by every trauma center and 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. Level I and II Trauma Centers: Trauma Registrars at Level I and II trauma centers are responsible for coding extensive injury complexes, procedures, complications, and prolonged hospitalizations. They are also responsible for coding additional data elements for the Trauma Quality Improvement Program (TQIP) and participate in required Georgia Quality Improvement Program (GQIP) state drill down exercises. The Trauma Registrar is an integral member of the Performance Improvement process within the Level I and II trauma center and assist with data re-review upon TQIP Benchmark report receipt biannually. Level III and IV Trauma Centers: Trauma Registrars at Level III and IV trauma centers are not responsible for coding additional data elements for TQIP (unless the Level III center is a participating TQIP facility). Patients with extensive injury complexes receive initial stabilization and are typically transferred out to Level I or II trauma centers when resources at these facilities are exceeded. The admitted, non-transferred out, patient population at the Level III and IV trauma centers usually have minimal procedures, lessened injury complexes, and shorter length of stays for coding. Burn Centers: Burn/Trauma Registrars are responsible for coding data elements in both the burn and trauma registries. The burn registry requires less data entry elements than the trauma registry, however, patients within this registry tend to have complex coding requirements secondary to necessitating multiple procedures and prolonged hospitalizations. 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:

1. Data Abstraction/ Entry a. 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. b. Utilizes technical coding principles expertise to assign appropriate ICD-10CM diagnoses and ICD-IOPCS procedure codes into trauma database. c. Utilizes technical trauma specific coding principles expertise to assign appropriate AIS codes used to calculate the ISS (injury severity score). d. Identifies activation levels and report to Charge Capture for appropriate reimbursement. e. Identifies records that fall within the Trauma Registry inclusion criteria for hospital, state and national registries. f. 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. g. Informs the Trauma Program Manager (TPM) of all relevant trauma audits filter inconsistencies via monthly Quality Assurance Reports h. 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. i. Meets productivity standards. A. Queries physicians when needed to further clarify code assignments. 4. Data Extraction and Reporting a. 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. b. Runs appropriate quality assurance reports and takes corrective action on errors in preparation for each data upload. c. Ensures all data uploads to the NTDB, TQIP, and State Trauma Registry are completed on time and documented for reporting. d. Produces various other Quality Assurance reports as requested by the TPM. e. 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. 2. Data Validation and Inter-rater Reliability a. 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 b. Maintains the highest level of validity to assure accurate program profiling, TQIP, state and internal data reports using based on defined processes. c. Completes routine checks of abstracted data for accuracy and maintains an accuracy rate of . Identifies suspicious or invalid cases, variables and data values, implements corrective action for invalid data, and reports findings to the Certified Trauma Data Analyst and TPM for further review. 3. Database Management a. Ensures security and privacy of all Trauma Registry related date in accordance with HIPPA and the Trauma Registry Data Management procedures. b. Ensures data is collected in compliance with National Trauma Data Standards (NTDS). c. Expands the database management program as needed to meet the needs of the Trauma Program. d. Serves as liaison with the registry software vendor and WHS IT department personnel. e. Ensures all software program updates are completed as needed. A. Ensures data backups are completed at scheduled intervals. 5. Other Duties a. Attends all Trauma Services meetings as requested. b. Participates in the Georgia Committee of Trauma Excellence (GCTE) Trauma Registry Subcommittee. c. Responsible for continued professional growth: must complete 8 continuing education hours annually as required by the ACS. May include: 1. TQIP Conference 2. TQIP Education Opportunities 3. TQIP Annual Course (on-line) 4. Hospital, WHS Trauma Center or state trauma education programs d. Helps to support regional and state trauma system development. Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• GED General or High School Diploma General-Preferred
• Associates Health Information Management-Preferred

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

All certifications are required upon hire unless otherwise stated.

Additional License(s) and Certification(s):

A minimum of 8 continuing education hours of trauma related continuing education hours are required annually. 20 CEUs during reporting cycle are required for RHIT recertification. ATS Trauma Registry Course (or equivalent course for trauma registrars) Upon Hire Required and AAAM AIS-08 (AIS-15 preferred) Coding Course Upon Hire Required RHIT - Reg Health Information Tech Upon Hire Preferred or CSTR - Cert Specialist Trauma Registr Upon Hire Preferred or CAISS - Cert Abbr Injury Scale Spec Upon Hire Preferred or

Required Minimum Experience:

Minimum 2 years Trauma Registry coding experience with RHIT Required or Minimum 3 years Trauma Registry coding experience without RHIT Required and Proficient in computer entry and data extraction; ICD-10CM and ICD-10PCS coding, AIS coding required. Required

Required Minimum Skills:

Proficient in computer entry and data extraction; ICD-10CM and ICD-10PCS coding, AIS coding required High Computer/data entry experience High Ability to communicate with various members of the healthcare team. High Ability to use EXCEL, Word and have basic computer operational knowledge. Epic, 3M High