Role Description
Under supervision by the Trauma Program Manager, the Trauma Registrar is responsible for the detailed review, abstraction and input of patient information into the trauma and burn registry databases.
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Concurrently and retrospectively collects data from patient electronic health records and various computer-generated sources on all trauma and burn patients admitted or referred to Hennepin Healthcare HCMC and/or with a Trauma Team Activation.
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Gathers accurate information to process records and determines trauma or burn patient eligibility inclusion criteria, accurately entering data into the trauma and/or burn registries.
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Encodes the data, including ICD-10 coding, trauma registry coding, abbreviated injury scoring (AIS), injury severity scoring (ISS), National Trauma Data Standards (NTDS) Data Dictionary, American Burn Association (ABA) Data Dictionary, and MNTrauma Data Dictionary, using pre-established guidelines.
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Maintains record keeping such as weekly time studies, tracking progression of completed and uncompleted cases, and continuing education credits.
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Ensures accurate data entry of all injuries, procedures, complications, and required data fields as established by the NTDS, ABA, and MNTrauma data dictionaries, and HHS-HCMC specific trauma registry data elements.
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Maintains code files and data dictionary.
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Actively participates in data validation processes for accuracy and consistency of abstracting.
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Participates in TQIP webinars, monthly education experiences, regularly scheduled registrar meetings, and Trauma Services huddles and staff meetings.
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Attends Minnesota Trauma Registry Alliance (MTRA) meetings as appropriate.
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Assists with preparation for trauma and burn center verification site visits.
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Assists with quality projects and research activities as directed.
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Performs additional responsibilities related to the Trauma Registry as assigned by the Lead Trauma Registrar, Trauma Program Manager, Trauma Medical Director, Trauma Data Analyst, Trauma PIPS Coordinators, Pediatric Trauma Coordinator, or Burn Program Coordinator.
Qualifications
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Completion of an Associateโs Degree or Bachelorโs Degree in Health Information Management -OR- An approved equivalent combination of education and work experience that includes:
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2-3 years of experience with medical terminology, anatomy, coding, data abstraction, and data management.
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Experience and working knowledge of the ICD-10 coding classification system, with the ability to search for all appropriate codes using the index.
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Successful completion of the following courses within 6 months of employment (if not done previously):
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ATS Trauma Registrar Course
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Trauma ICD-10 Diagnosis and Procedure Coding Course
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AAAM Injury Severity Scoring Course
Requirements
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RHIT (Registered Health Information Technician) or RHIA (Registered Health Information Administrator) preferred.
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Certified Abbreviated Injury Scale Specialist (CAISS) preferred.
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Certified Specialist in Trauma Registry (CSTR) preferred.
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Trauma Registrar experience at a Level I or II Trauma Center preferred.
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Burn Registrar experience at a verified Burn Center preferred.
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Successful completion of the ATS Trauma Registrar Course preferred.
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Successful completion of a Trauma ICD-10 Diagnosis and Procedure Coding Course preferred.
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Successful completion of AAAM Injury Severity Scoring Course preferred.
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Working knowledge of ESO TraumaBase, ESO Burn Registry, or BData/BCQP burn registry databases preferred.
Knowledge/Skills/Abilities
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Computer skills with proficiency in Microsoft programs and EMR software.
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Abide by strict confidentiality regulations as defined by HIPAA and hospital policy.
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Ability to research information.
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Critical thinking and problem-solving skills.