Rehab

Trauma Registrar Registered Nurse

Location: Albany GA

The Trauma Registrar is responsible for the collection and abstraction of required state and national trauma data bank elements into the Trauma Registry database on all patients meeting state or national trauma inclusion criteria. The Trauma Registrar maintains the confidentiality of the registry data and provides registry data as appropriate for research. Responsible for working with patients staff and physicians in multidisciplinary specialties such as orthopedic surgical neurosurgery cardiothoracic plastics oral maxillofacial emergency medical services (EMS / pre-hospital) and pediatric subgroups. Participate in trauma rounds to ensure trauma patient tracking is thorough and complete. The Trauma Registrar will consult with medical staff and patients care providers in the following specialties which include but are not limited to ventilator status consults procedures blood products and diagnosis of trauma outcomes as they occur. Utilize data to conduct registry tracking trending and surveillance. Provide data analysis to support trauma services and leadership in making adjustments to trauma protocols/guidelines and support injury prevention and quality initiatives for our community and regional communities. May provide data for and participate in grant submissions and other required reporting. Performs all other related duties as assigned.

Qualifications

Associate's Degree in Nursing (Required)
Completion of ICD-10 Coding Program or Equivalent Experience. If not previously completed must be completed within ONE (1) year of hire:
The American Trauma Society's Trauma Registry Course
The Association of the Advancement of Automotive Medicine's Injury Scaling (Required)
Work Experience
3 years of nursing experience (Required)
2 years of trauma nursing experience (Required)
1 or more years of coding experience or previous experience working with trauma registry databases and handling medical information in the healthcare system (Required)
Licenses and Certifications
Certified Abbreviated Injury Scale Specialist (CAISS) within two (2) years of hire (Required)
Certified Specialists in Trauma Registry (CSTR) within two (2) years of hire (Required)

Essential Functions

TRAUMA REGISTRY RESPONSIBILITIES
Maintains the trauma registry.
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.
Keeps registry current as defined by the American College of Surgeons (ACS) as 80 complete within 60 days of patient discharge.
Determines appropriateness of patient entry into the Trauma Registry based on guidelines in the American College of Surgeons Resources for the Optimal Care of the Injured Patient as well as the National Trauma Data Standard.
Provides high quality data entry by abstraction of required state and national trauma data elements from the patient chart in real time and retrospectively.
Participates in quality assurance data validation and improvement activities to ensure accuracy of data collection and timely submission of data according to State Trauma Registry and the American College of Surgeons Optimal Resource Document for Trauma Centers.
Understands mapping concepts and validates mapping of registry software for Trauma Quality Improvement Program (TQIP) National Trauma Data Bank (NTDB) and the state.
Resolves routine coding issues/problems and appropriately seeks assistance from Trauma Program leadership and/or Trauma Registry vendor when appropriate.
Recognizes patterns of mechanism and injury during case abstraction in order to contribute to opportunities for injury prevention and community safety.
Reports data in formats such as Excel and/or PowerPoint for both internal and external consumption (includes statistical clinical and research data).
Attend bi-monthly Georgia Trauma Coordinator/Registrar meetings.
Attend trauma registry-related continuing education courses organized by the State Office of EMS & Trauma.
Take Trauma Committee meeting minutes.
Participates in organizing annual trauma conference sponsored by the Georgia Trauma Coordinators & Registrars.

Clinical Knowledge

Must have completed coursework in physiology anatomy and medical terminology. Experience with electronic health records. Monitors patient care plans to record and communicate to the trauma team and further document in the trauma registry. Assessment and coordination of patient's discharge planning needs with members of healthcare team. Rounding with trauma team to identify any outcome or care issues that need to be addressed timely.

Documentation

Documents and submits required information and data in a timely fashion. Clearly and accurately documents designated processes policies products service offerings etc. Ensures that documentation is tailored to expected readers/users. Uses correct terminology. Conforms to required style and format.

Additional Duties

Adheres to the hospital and departmental attendance and punctuality guidelines. Performs all job responsibilities in alignment with the core values mission and vision of the organization. Performs other duties as required and completes all job functions as per departmental policies and procedures. Maintains current knowledge in present areas of responsibility (i.e. self-education attends ongoing educational programs). Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time. Demonstrates competency at all levels in providing care to all patients based on age sex weight and demonstrated needs. For non-clinical areas has attended training and demonstrates usage of age-specific customer service skills. Wears protective clothing and equipment as appropriate.