Trauma Registrar 1

Job Description

This position is accountable for the collection, completion, and verification of the accuracy of all patient data collected for the Trauma Registry data collection system. The Registrar creates and maintains clinical and statistical data, AIS coding, ICD10CM codes and abstracts various data elements required ensuring consistency and quality in all aspects of the system through data collection. Responsibilities include daily monitoring of trauma admissions for record identification, abstracting, coding and entering data into the registry.

Responsibilities

1. Medical Records and Coding
   1. Identifies the trauma patient medical records. Monitors Emergency Department, Admitting department, and Trauma Team activation pages daily for trauma admissions.
   2. Performs concurrent/retrospective abstraction from the trauma patients medical record of relevant information required for the Trauma Registry. Takes initiative for finding lost information. This includes contacting pre-hospital care agencies for missing run sheets.
   3. Abstracts core information from patient medical records (including demographic characteristics, history of injuries, diagnostic procedures and treatment, laboratory values and medical complications) and enters select information from trauma patient records to Trauma 1 database.
   4. Accurately assigns codes including diagnoses and procedures using ICD-10-CM and AIS coding. Determines the appropriate sequencing of diseases, diagnoses, and surgeries.
   5. Maintains patient confidentiality including confidentiality of sensitive hospital performance improvement information.
2. Quality and Performance Improvement
   1. Assists with organization and participates in committees such as: Trauma M&M/Multidisciplinary Peer Review Conference and Trauma Operations meetings.
   2. Maintains continuing education related to trauma registry and PI.
3. Other Duties as Assigned
   1. Performs other duties as assigned or requested.

Qualifications

Experience:
1 year of ICD and/or AIS coding experience. Internship/school training may be substituted for year experience.

Education:
Associate Degree in Health Science or Allied Health related field or Health Information Management


Training:
Successful completion of the Trauma Registry Course is required within the first year of employment.

About Us

Our Lady of the Lake is uniquely capable of caring for a full range of illness or injury, including those that are extremely complex, for both pediatric and adult patients. Our family of services includes:

• An 988-bed hospital and the area's only Level I Trauma Center
• A freestanding Children's Hospital
• A 545-provider care network covering more than 40 specialties
• Two free-standing emergency rooms-Our Lady of the Lake Livingston and Our Lady of the Lake North
• A network of nearly 15 urgent care clinics
• Outpatient imaging and surgery centers
• Assumption Community Hospital
• Franciscan Missionaries of Our Lady University
• Our Lady of the Lake Ascension, a 78-bed, community hospital providing emergency, inpatient, outpatient, and surgical services to Ascension Parish and surrounding areas

We serve 38,000 inpatients and 820,000 outpatients annually and are committed to building a healthy community through excellence in patient care and education. A part of FMOL Health, Our Lady of the Lake is consistently awarded for compassionate care, clinical expertise, leading edge technology and innovation.