Trauma Registrar

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UPMC Western Maryland is seeking a Full-time Trauma Registrar to support our Trauma Center.

This is a full-time, 40 hr/wk dayshift position that will be working in the trauma services office abstracting data from patient charts and performing trauma tri-coding for entry into the Maryland Trauma Registry.

Responsibilities:

• Document data and time of attendance at continuing education programs.
• Demonstrate an awareness of the hospital's commitment to provide excellence in trauma patient care by supporting the Trauma Program's service management objectives.
• Perform related responsibilities as requested by the Trauma Program Manager.
• Follow protocol for removing or adding patients to the database.
• Identify trauma patients appropriately by monitoring on a daily basis the Emergency Department and Admitting Department identification systems.
• Perform additional trauma patient medical record abstracting or audit activities for quality assurance, research, education, or for the purpose of identifying and addressing documentation deficiencies.
• Engage in follow-up activity as appropriate.
• Accurately maintain the computerized registry system, which includes keying data, making additions, and making corrections as necessary.
• Contact the Trauma QA/Registry Coordinator for problem-solving and clarification of clinical information.
• Maintain the statistical database accurately, generate routine monthly reports, and respond to special requests for statistical information.
• Work with the Trauma Nurse Specialist and Trauma QA/Registry Coordinator to collect, organize, and disseminate results.
• Maintain confidentiality of patient information and follow hospital policies relating to security of patient information.
• Ensure that all PTOS information is accurate, complete, and submitted within the time frames established by PTOS protocol.
• Maintain communications with the state Trauma Registrar and/or PTOS analysts for purposes of clarifying information or responding to requests for clarification of information.
• Maintain and expand current knowledge base through attendance at appropriate in-services or seminars and by studying reference material.
• Abstract from the trauma patient medical record relevant information required for the hospital registry, including selection and coding of diagnoses and procedures using ICD9-CM, and calculation of trauma and Injury Severity Scores accurately and efficiently.
• Retrieve information from the database upon request of Trauma Services or other appropriate personnel. Determine the data elements and design the output for the request.
• Attend and participate in Trauma QI activities such as MAC meetings.
• Conduct concurrent review of trauma patient records within 48 hours of admission and enter select information into the database to provide current information for quality assurance, outreach, education, and public relations purposes.
• Document and disseminate information as appropriate.

• High School Diploma with a minimum of 3 years of trauma registry, coding and/or abstracting experience OR a Graduate of an accredited record technician program or an Associate Degree with 1 year of trauma registry, coding and/or abstracting experience.
• Knowledge of medical record content, medical terminology, anatomy, and physiology is required.
• Prior experience in coding is required.
• Experience in computer data entry, databases, and data retrieval is desirable. Licensure, Certifications, and Clearances: UPMC is an Equal Opportunity Employer/Disability/Veteran