Trauma Registrar 1

Summary

FMOL Health, through Our Lady of the Lake Hospital, provides comprehensive medical care including trauma services. The Trauma Registrar 1 collects, abstracts, codes, verifies, and maintains clinical and statistical trauma registry data while monitoring trauma admissions and supporting quality and performance improvement activities.

Responsibilities

• Identifies the trauma patient medical records. Monitors Emergency Department, Admitting department, and Trauma Team activation pages daily for trauma admissions
• Performs concurrent/retrospective abstraction from the trauma patients medical record of relevant information required for the Trauma Registry. Takes initiative for finding lost information. This includes contacting pre-hospital care agencies for missing run sheets
• Abstracts core information from patient medical records (including demographic characteristics, history of injuries, diagnostic procedures and treatment, laboratory values and medical complications) and enters select information from trauma patient records to Trauma 1 database
• Accurately assigns codes including diagnoses and procedures using ICD-10-CM and AIS coding. Determines the appropriate sequencing of diseases, diagnoses, and surgeries
• Maintains patient confidentiality including confidentiality of sensitive hospital performance improvement information
• Assists with organization and participates in committees such as: Trauma M&M/Multidisciplinary Peer Review Conference and Trauma Operations meetings
• Maintains continuing education related to trauma registry and PI
• Performs other duties as assigned or requested

Skills

• 1 year of ICD and/or AIS coding experience
• Internship/school training may be substituted for year experience
• Associate Degree in Health Science or Allied Health related field or Health Information Management
• Successful completion of the Trauma Registry Course is required within the first year of employment

Qualifications

Must Haves

• 1 year of ICD and/or AIS coding experience
• Internship/school training may be substituted for year experience
• Associate Degree in Health Science or Allied Health related field or Health Information Management
• Successful completion of the Trauma Registry Course is required within the first year of employment

Benefits

• Full-time employment
• Remote workplace