PURPOSE OF POSITION :
The trauma registrar is responsible for assisting in the collection of data for all injured patients cared for at the trauma center. The trauma registrar will assist in the verification of the accuracy of all patient data in the NYC Health + Hospitals: Lincoln Trauma Registry along with co-registrar validation. The trauma registrar will assist the trauma program manager, trauma PI coordinator, and trauma medical director in using the trauma registry for quality and process improvement projects and trauma-related research. The trauma registrar will complete all courses required by the American College of Surgeons Committee on Trauma (ACS-COT) for registrars at Level I trauma centers. The trauma registrar will maintain clinical and statistical data, AIS and ICD-10 codes, and abstract various data elements from the pre-hospital records, the electronic medical records, and when applicable autopsy reports. The trauma registrar will assist with data protection and security and in the submission of required data to the State of New York Trauma System, the National Trauma Data Bank and the Trauma Quality Improvement Program – both national and New York State. The trauma registrar will report to the trauma program manager and work with the trauma team in trauma-related PI, outreach, education, and research efforts.
DUTIES & RESPONSIBILITIES:
Data Collection
Identifies patients to input into the trauma registry per trauma program inclusion/exclusion criteria.
Collects and analyzes data on trauma patients that are detailed, reliable, and readily accessible; concurrent collection through chart review and staff interview if preferred.
Performs basic data collection of demographics, and coding of clinical and follow-up data from all sources into trauma registry database. Interacts with physicians, nurses, and other members of the trauma team and trauma patients to perform trauma registry functions. Keep the registry current within 60 days of patient discharge.
Enters data daily into the trauma registry, analyzing patient records for data entry points as well as looking for possible quality/safety issues.
Abstracts assemble, enter, and code clinical data with 95% accuracy into a computer database by using the Association for the Advancement of Automotive Medicine Abbreviated Injury Scale (AIS), current ICD 10 coding, and all current registry users’ operations and standards manual information and NYC Health + Hospital trauma registry policies and guidelines.
Data Reporting
Submits clean data (de-identified and secure) to the New York State Trauma Registry, National Trauma Data Bank, and National and State Trauma Quality Improvement Programs as required and on the due dates.
Produces reports from trauma database in Microsoft Word, Excel, or PowerPoint as requested by trauma staff after approval by the trauma medical director and if applicable for research the IRB.
Participates in quality assurance and improvement activities to ensure the accuracy of data collection and timely submission of data according to trauma center and external verification and certification agencies.
Data Validation
Participates in the process of validation of registry data.
Data Security/Patient Confidentiality
Maintains patient confidentiality including confidentiality of sensitive hospital performance improvement information.
Other
Resolves routine coding issues/problems and appropriately seeks assistance from trauma registry vendor staff for the more difficult issues.
Participates in trauma process improvement and ACS-COT required committee meetings and educational conferences to maintain and expand trauma registry knowledge base.
Identify opportunities for process improvements provide analysis and propose change and communicate strategies.
Participates in internal and community outreach education on injury prevention, trauma systems, and trauma data.