HIM Trauma Registrar (PRN) - Trauma Services, University Hospital

USA Health•Mobile, AL

About The Position

The HIM Trauma Registrar reviews hospital registration, admission, death, and medical records to identify trauma cases and enter required information into approved trauma registry software. The position abstracts and codes trauma data, including trauma-specific injuries and AIS scores, and supports data quality and quality improvement in accordance with standards established by the Trauma Medical Director, Trauma Program Manager, and American College of Surgeons. The registrar maintains the confidentiality and security of patient data, follows established procedures for retrieving and processing registry data, prepares reports on the hospital’s trauma experience, and compiles patient-care information for the monthly Quality Improvement Program as needed. The role also attends weekly trauma conferences and maintains official minutes. The position requires accurate recordkeeping, effective communication with physicians, patients, families, and healthcare team members, and cooperation with colleagues and incoming shifts. The registrar must complete mandatory training and other hospital requirements, follow infection control, safety, confidentiality, and dress-code policies, maintain regular and prompt attendance, and work the defined schedule and overtime as required. Related duties may be assigned.

Requirements

High school diploma or equivalent.
Two years of related experience in Health Information Management, unless substituted by a preferred RHIT or RHIA credential or a comparable combination of education and experience.
Knowledge of ICD-10-CM and AIS coding.
Complete eight hours of registry-specific training per year.
Ability to work the defined schedule and overtime as required.

Nice To Haves

Registered Health Information Technician (RHIT); this credential may substitute for the required experience.
Registered Health Information Administrator (RHIA); this credential may substitute for the required experience.

Responsibilities

Follow compliance requirements, organizational policies, ethical standards, hospital confidentiality policies, infection control and safety standards, and the approved dress code.
Review Emergency Department registration and admission records daily to identify trauma admissions for entry into the trauma registry software.
Screen inpatient, outpatient surgery, and emergency death reports to identify trauma cases.
Review electronic medical records and collect and abstract information according to standards set by the Trauma Medical Director, Trauma Program Manager, and American College of Surgeons.
Enter required core patient information into approved software.
Maintain the confidentiality and security of patient data stored in the Trauma Registry.
Code trauma-specific injuries and assign AIS scores.
Maintain quality control of case finding, abstracting, coding, and data-processing procedures.
Retrieve trauma data manually or by computer using established procedures.
Respond to data requests as assigned.
Prepare routine and special reports summarizing the hospital’s trauma experience.
Compile patient-care data across pre-hospital, Emergency Department, and acute inpatient phases for the monthly Quality Improvement Program as needed.
Attend weekly trauma conferences and transcribe and maintain official minutes.
Maintain accurate logs and other required reports, use correct documentation tools and procedures, and conduct concurrent rounding with the trauma team when applicable.
Verify fax transmissions by reviewing the fax log.
Communicate appropriately with physicians, patients, families, and healthcare team members in person and through telephone, email, fax, and other methods.
Relay unfinished requests and duties to incoming shifts and send secure-format emails when needed.
Cooperate with colleagues, help others, and support unit performance.
Complete mandatory unit, department, educational, and hospital requirements.
Use cost-effective practices, maintain regular and prompt attendance, work the defined schedule and overtime as required, and perform related duties as assigned.