Trauma Registrar is responsible for the overall collection and retention of pertinent data concerning trauma patients. This responsibility includes identifying appropriate patient cases; identifying appropriate data for collection; data collection; assigning AIS codes for all injuries; reviewing ICD-9CM/ICD-10CM codes and assigning additional codes as needed; assisting with monitoring of Performance Improvement indicators, data entry and retention; generating reports; maintaining the registry program so as to keep data current based on changing trends in trauma care; promoting favorable guest relations and expressing the values of the hospital philosophy in daily work activities.
1. Address patients, visitors, families, and co-workers with respect and professionalism.
2. Respond quickly and appropriately to requests.
3. Assist co-workers without being asked.
4. Maintain confidentiality for all patients-hospital or physician related information. Adhere to the organizations code of conduct. Access medical information only when required to do so as part of the duties of your position.
5. Promote related assignments as requested in order to promote positive relationships with all patients, visitors, and co-workers.
· Communicate, cooperate, and perform related duties with other co-workers in your department and in other departments in a courteous and efficient manner to achieve overall hospital goals and objectives.
· Handle requests with a professionalism and accurate assessment of timetable.
· Assume responsibility for maintaining healthy interpersonal relationships with all those working or being cared for in the hospital, outpatient, or home setting.
· Demonstrate a commitment to providing the highest and most reliable quality service available on a daily basis.
· Strive for process and workflow improvement in your work area. Cooperate with team members in a constructive and supportive manner.
· Be responsible for addressing inappropriate or unacceptable behavior. Document and report issues according to the Confluence Health code of Conduct.
· Demonstrate ethical conduct and practices.
6. Performance consistent with Trauma Services Vision and Constitution: Providing excellence in patient care and Customer satisfaction. Team members will:
· Have ownership in Trauma Services and its appearance, operation, and growth.
· Show professionalism in their words, actions, attitude and appearance.
· Communicate honestly and respectfully.
o Treat others professionalism and respect.
o Participate in open intra/interdepartmental communication.
· Be accountable for their actions and words.
· Embrace change and be flexible.
· Work toward continuous improvement.
· Do the right thing, at the right time, for the right reasons.
· Be fiscally responsible and use resources appropriately.
· Know their limits, utilize their team and vocalize if a task or assignment is beyond their ability to perform.
· Be caring and empathetic in actions and words.
· Value others' time and effort equally.
· Ensure a safe working environment for patients and staff.
· Work towards improving the trauma program.
7. Collect, abstract, and accurately enter trauma patient information into trauma registry in a timely manner. Communicate delays in work process or flow to Trauma Coordinator.
8. Identify and record quality improvement issues identified in the initial data entry of the trauma patient record, and those issues identified by the Trauma Coordinator during the patient's hospital stay, in the trauma registry.
9. Ensure correct demographic information and code charges are entered into Collector.
10. Abstracts core data, involving all phases of trauma care, from the medical record, according to established guidelines, utilizing the Trauma Coordinator
11. Interacts with other areas, e.g. software manufacturer, EMS companies, nursing units, Coroner's office, to ensure accurate data collections.
12. Reviews ICD-9/ICD-10 CM codes for accuracy, making additions/corrections as necessary.
13. Assigns AIS (Abbreviated Injury Scale) codes for all injuries.
14. Accurately enters data into the trauma registry via computer. Classifies and stores data in such a way as to make it easily retrievable.
15. Assists with monitoring of Performance Improvement indicators.
16. Develop and provide reports to trauma services and other individuals or departments as needed.
17. Maintain security of trauma registry to ensure patient confidentiality.
18. Analyze, summarize and display data in a variety of formats for the purpose of reporting using Access, Word, Excel and PowerPoint.
19. Assists with trending of indicators.
20. Collaborates with the Trauma Program Manager and Trauma Medical Director in the overall duties and vision of Trauma Services.
21. Provides additional administrative support to Emergency Services Director and Clinical Director as needed.
Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.
- High School graduate or equivalent.
- Training in secretarial science and word processing.
- Typing skill of 60+ words per minute.
- Knowledge of medical terminology and abbreviations.
- Must possess basic computer skills related to Windows navigation, mouse usage, keyboarding, email communication and password management.
- Knowledgeable and proficient in a wide variety of computer software programs (Access, Excel, Word, PowerPoint, Internet).
- Must be able to sit for extended periods of time.
- Must meet work deadlines in spite of interruptions.
- Must have ability to prioritize workload.
- Independent action and decision making expected.
· Two years previous secretarial experience.