Trauma Registrar

The Trauma Registrar is responsible for the identification of patients for inclusion, abstraction into, and reporting of, trauma patients in the Trauma Registry. This registry is maintained in accordance with national, state, local, and organizational rules, conventions, and guidelines. The trauma registry is utilized for reporting, research, prevention initiatives, and performance improvement. This data is collected through multiple sources, including, but not limited to: Emergency Medical Services (EMS) run sheets; the electronic medical record (EMR); and trauma flow sheet.  The registrar will code and enter data into the electronic trauma registry, while maintaining the integrity and confidentiality of data and information.

Responsibilities

Under the direction and supervision of the Trauma Program Director (TPD), the Trauma Registrar is responsible for:

• Identifying patients that meet criteria for entry into the trauma registry, utilizing all available resources, in accordance with national, state, local, and organizational rules, conventions, and guidelines
• Abstracting accurate, thorough, high-quality data from the EMR into the Trauma Registry, for each patient identified and assigned to them, in accordance with the National Trauma Data Standard (NTDS) and New York State Data Dictionary
• Assigning and scoring all injuries using the Abbreviated Injury Scoring (AIS) and ICD-10 coding systems
• Maintaining concurrent trauma registry (at least 80% of patient records completed within 60 days of hospital exit), in accordance with current American College of Surgeons (ACS) requirements and standards
• Submitting data to the National Trauma Databank (NTDB), Trauma Quality Improvement Program (TQIP), and New York State (NYS) Trauma Registry in accordance with the schedules required by those entities
• Participating in Inter-Rater Reliability (IRR) data validation, feedback, and correction activities
• Running registry reports as requested by the Trauma Medical Director (TMD), TPD, and/or PI Team.
• Assisting with the preparation of reports and data for any and all trauma-related meetings, research, and reporting as directed by the TMD and TPD
• Identifying, analyzing, and reporting patient safety and quality concerns, both on a case-by-case and aggregate basis, to the TPD and Trauma Performance Improvement (PI) Team
• Maintaining annual continuing education (CE) requirements in accordance with ACS standards
• Attending and participating in organization, local, regional, state, and national trauma meetings and conferences
• Other and additional tasks and duties as assigned

Tagged as: caiss, cstr, trauma registrar