Trauma Registrar - Penn Presbyterian Medical Center

Trauma Registrar

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The Trauma Registrar is responsible for the collection/abstraction and validation of data elements required by the trauma center, state and national databases 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 trauma center reporting and research. In addition to competency in computer skills, the Trauma Abstractor/Registrar must have experience and demonstrate skills in the following areas; ICD10 injury and procedure coding, understanding of basic anatomy, customer service orientation, time management principles, cost containment and interpersonal relationship skills. The Trauma Registrar is accountable for maintaining productivity standards set forth by the Division and State and National Standards for standard trauma registry work. This position is full-time and reports to the Trauma Program Manager.

Responsibilities:

• 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 The Pennsylvania Trauma Systems Foundation (PTOS), American College of Surgeons Resources for the Optimal Care of the Injured Patient as well as the National Trauma Data Standard and Trauma Quality Improvement Program (TQIP) and others as outlined by the Division.
• Provides high quality data entry by abstraction of required state and national trauma data elements from the EMR in real time and retrospectively
• Maintains data accuracy and timeliness of submission as per state and national benchmarks. 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), the state (PTSF) and others as identified by the Division.
• Resolves routine coding issues/problems and appropriately seeks assistance from Trauma Program leadership, Trauma Performance Improvement 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 from the Trauma Registry Databases and in formats such as Excel and/or PowerPoint for both internal and external consumption (includes statistical, clinical, and research data).
• Maintains continuing education as per Division, state, and national benchmarks.
• Supports and participates in the research efforts of the Division a and the University of Pennsylvania Trauma Network Services.
• Assists with Performance Improvement functions, facilitating an interface between the performance improvement program and the trauma registry.
• Participation in PTSF/Division meetings and mandatory training sessions is expected.
• Maintains certifications and continuing education as mandated by the PTSF/ ACS standards for trauma center accreditation.
• Maintains strict confidentiality of all patient information in accordance with hospital policy.
• Abstracts customized data elements needed to support trauma program functions for all patients accessioned into the trauma registry.
• Identifies and flags ESS patients for the Division regardless of entity.
• Assists in obtaining autopsy reports for all trauma related deaths from the Medical Examiners Office and updates injury diagnoses into the registry as delegated by the Trauma Registry Coordinator.
• In collaboration with the Division Management interfaces with external organization to promote educational and professional development (PTN, ATS, AAPC, AHIMA, Colleges, Vendors, PTSF etc.)
• Participates in the accreditation/site survey process.
• Participates in state, national, Hospital or Divisional committees as appropriate

Credentials:

Education or Equivalent Experience:

• Associate of Arts or Science (Required)
• Education Specialization: Health Information Management or related field Equivalent Experience: Or 3+ years Trauma registry experience
• Bachelor of Arts or Science
• Education Specialization: Health Information Management or related field Equivalent Experience: If not previously completed, within one (1) year of hire attend: 1. The American Trauma Societys Trauma Registrar Course or equivalent provided by a state trauma program AND 2. The Association of the Advancement of Automotive Medicines Injury Scaling Course 3. PTSF Trauma Registry Course

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work

We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.