Registrar Trauma, Trauma Service

Overview

Registrar Trauma, Trauma Services

40 hours per week, day shift

JOB SUMMARY:  Responsible for the identification, abstraction, entry, validation, productivity, and quality of ICD9-10 CM-PCS and AIS coding of data for AHWFB Level 1 Trauma and Burn Center adult registry database as required by appropriate regulatory agencies to include American College of Surgeons, American Burn Association and North Carolina Office of Emergency Management.  The data shall be obtained from the patient electronic medical record including EMS and referring facilities.

EDUCATION/EXPERIENCE:

• High School diploma or equivalent, college degree preferred
• Trauma Registrar experience preferred
• Abbreviated Injury Scoring (AIS) course completion required within 1 year of hire
• Certified Specialist Trauma Registry course completion required within 1 year of hire
• ICD10 course completion required within 1 year of hire

LICENSURE, CERTIFICATION, and/or REGISTRATION:

• Certified Professional Coder (CPC) certification required, CSTR recommended, CAISS certification when standards are met

ESSENTIAL FUNCTIONS:

1. Identifies trauma/burn patients to enter into the registry database according to regulatory agencies,
2. Abstracts and enters data from the patient’s medical record including EMS and referring facility into the registry database ensuring confidentiality of patient information per hospital policy. 
3. Ensures timely and accurate Trauma and Burn registry data entry and coding according to regulatory agencies. Participates in all inter-rater reliability and data validation activities.  Maintains productivity standards per regulatory agencies and department guidelines.  Runs database reports to support productivity.
4. Maintains documentation of registry activity
5. Participates in departmental, local, state, national educational offerings and staff meetings as indicated.  Maintains 8 hours of trauma continuing education/year
6. Maintains current knowledge of registry requirements and coding ICD9-10, AIS, and TQIP through collaboration with peers, vendor, and regulatory agencies by attending conferences, webinars or conference calls. 
7. Assists in other aspects of the WFBMC Trauma Services Department as deemed appropriate by the Trauma Program Manager (assist with database reports to support PI, epidemiology, outcomes, and survey process).
8. Promotes a cooperative work environment by utilizing appropriate communication skills, interpersonal relationships, and team building. Maintains responsibility for keeping informed about changes in policy/procedure.