Trauma Registrar-UPMC Mercy Community Care Building

About the role

Are you detail-oriented, analytical, and passionate about improving patient outcomes? Join our team as a Trauma Registrar, where you'll play a vital role in supporting our trauma program through the collection, validation, and management of critical patient data. In this position, you'll accurately abstract and maintain trauma registry information, monitor data quality, assist with reporting requirements, and contribute to performance improvement initiatives that enhance patient care. The ideal candidate has strong organizational skills, excellent attention to detail, and the ability to work collaboratively with clinical teams while ensuring compliance with trauma registry standards and regulatory requirements. If you thrive in a data-driven healthcare environment and are committed to excellence, we encourage you to apply and make a meaningful impact on trauma patient care.

Purpose

• Maintain the efficient operation of the Trauma Patient Registry.
• Ensure consistency and quality in the data collection system.
• Identify trauma patients, admissions, abstracting, coding and entering information into the trauma database.
• Retrieve data for quality assurance purposes.
• Ensure compliance with Pennsylvania Trauma Systems Foundation requests for data.
• Work closely with the Trauma QA/Registry Coordinator and Trauma Program Manager.
• Interact with Medical Records, Information Services personnel, and patient unit staff.

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 appropriately trauma patients 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 appropriately the Trauma QA/Registry Coordinator for problem solving and clarification of clinical information.
• Maintain accurately the statistical database, 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 respond 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 and the Pennsylvania Trauma Outcome Study, including selection and coding of diagnoses and procedures using ICD-9-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.

Requirements

• 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.
• Demonstrated knowledge of medical record content, medical terminology, anatomy and physiology.
• Prior experience in ICD-9 coding.
• Desire abbreviated Injury Scoring (AIS).
• Demonstrated experience in computer data entry, databases, and data retrieval is desirable.

Licensure, Certifications, and Clearances

• Act 34