[Hiring] Hospital Registrar @Network ESC

Role Description

The Trauma Registrar is responsible for assisting with the coordination and maintenance of the Health System’s adult and/or pediatric Trauma Registry to meet organizational standards and Level I Trauma Center accreditation and verification requirements.

• Locate qualifying trauma cases and gather clinical information.
• Document patient data from various resources, including electronic health records, emergency medical service reports, and additional healthcare databases.
• Review medical records, evaluate clinical findings, and apply ICD-10 diagnosis codes and specialized classification systems, such as Abbreviated Injury Scale (AIS) scoring.
• Examine patient charts and maintain complete and accurate records within the trauma database.
• Recognize potential complications and report data discrepancies.
• Participate in quality assurance and performance improvement initiatives.
• Follow established data collection procedures, coding guidelines, and regulatory standards.

Qualifications

• CPC, CCS, RHIT, or another comparable medical coding or health information credential is preferred.
• Minimum of one year of experience in healthcare documentation, medical coding, or clinical record review.
• Background in trauma registry or surgical registry data collection and coding is beneficial.
• Strong computer skills, including familiarity with Microsoft Office applications, spreadsheets, word processing programs, and database systems.
• Familiarity with state and national requirements governing medical record abstraction and registry reporting.
• Knowledge of healthcare terminology, medical abbreviations, diagnoses, surgical procedures, associated conditions, and patient complications.
• Ability to accurately collect, record, review, and validate medical information while maintaining consistency and data accuracy.
• Ability to understand clinical documentation and apply appropriate medical coding standards.

Requirements

• Review assigned patient charts daily to collect information needed for trauma registry documentation.
• Identify patients who meet the criteria for entry into the trauma database.
• Gather and organize patient information from electronic health records, prehospital reports, and other clinical resources.
• Select and apply the appropriate ICD-10 codes and specialized injury classifications, including AIS scores.
• Examine medical documentation to identify diagnoses, injuries, treatments, existing medical conditions, and complications.
• Maintain and update registry records while ensuring information is complete, correct, and entered within required timeframes.
• Recognize reporting concerns, missing information, and potential patient care issues and notify the Supervisor when necessary.
• Follow established documentation practices, coding procedures, and applicable regulatory guidelines.
• Assist with departmental quality monitoring, data review, and trauma program improvement projects.

Independent Judgment and Case Complexity

The Trauma Registrar is expected to independently complete assigned medical record reviews, interpret patient information, determine appropriate coding, and maintain registry documentation.

• Assigned cases typically range from routine to moderately complex.
• Cases may involve patients with multiple traumatic injuries, additional medical conditions, serious complications, or death.
• The position requires attention to detail and the ability to evaluate clinical records.
• Appropriate application of coding and data abstraction standards is essential.