Trauma Registrar

Definition:
Under the Trauma Program Manager's (TPM) direction, this position is responsible for coding and abstracting all trauma patient's records at Ventura County Medical Center.
Maintains current accurate data within the trauma registry by collecting, entering, retrieving and reporting data related to all trauma patients treated at Ventura County Medical Center.
To establish supportive documentation qualifying the Medical Center as a Level Two Trauma Center.




Distinguishing Characteristics:
This classification is unique in that it requires specialized knowledge and certificates relating to medical coding /records.




Essential Functions/Duties:
Duties may include but are not limited to the following:
Collects trauma patient information through chart requisition and medical records.
Accurately enters demographic and visit information into the trauma registry for every trauma patient treated.
Identifies, prepares, and distributes a list of the trauma patient census to the trauma surgeons, trauma program manager, and trauma nurse coordinators.
Prepares monthly summaries of all trauma-related reports.
Codes injury severity using Abbreviated Injury Severity (AIS) score & International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10CM) for all traumatic injuries using doctor/nurses' notes, pre-hospital information and radiology reports.
Codes mechanism of injuries using ICD-10.
Codes all procedures using International Classification of Diseases, 10th Revision, Clinical Modification and Procedure Coding System (ICD-10CM/PCS).
Examines provider documentation for completeness and accuracy in accordance with ACS (American College of Surgeons) dictionary standards.
Determines when additional clinical documentation is needed in order to assign and/or validate injuries or procedure codes.
Enters appropriate trauma tiers for billing purposes in the EHR (Electronic Health Record) daily.




Provides statistical data as requested by members of the trauma team.
Ensure reporting and verification requirements for American College of Surgeons (ACS) National Trauma Data Bank (NTDB), or any other governmental reporting agencies are met.
Develops and implements a variety of performance improvement mechanisms through the trauma registry to consistently ascertain compliance with trauma standards under direction of Trauma Program Manager.
Assists with the identification, investigation, reporting, and follow-up of incidents and quality issues throughout the program while maintaining confidentiality.
Creates meaningful reports to support overall quality monitoring and specific improvement initiatives. Prepares reports from registry as necessary.
Provide administrative support to the Trauma Program Manager and Trauma Medical Director.
Performs other related duties as assigned.




Qualifications/Skills, and Abilities:
Demonstrate medical terminology knowledge; computer skills (Word & Excel) as well as effective communication skills.
All staff members who have registry role in data abstraction and entry, injury coding, ISS calculation, data reporting, or data validation for the trauma registry must fulfill all the following requirements:




Participate in and pass the AAAM's Abbreviated Injury Scale (AIS) course for the version used at VCMC after 6 months of hire.
Participate in a trauma registry course that includes all the following content within 6 months of hire:
Abstraction
Data management
Reports/report analysis
Data validation
HIPAA
Participate in an ICD-10 course within 6 months of hire or an ICD-10 refresher course every five years.
Trauma registrar must accrue at least 24 hours of trauma-related CE during the verification cycle.




Necessary Special Requirement:
Pass the CAISS (Certified Abbreviated Injury Scale Scoring) test after 2 years of coding.
Experience as a Health Unit Coordinator, or related position preferred.
This position has no responsibility for providing care to patients.
Applicants must demonstrate the potential ability to perform the essential functions of the job as outlined in the position description.