Trauma Registrar-UPMC Mercy Community Care Building

UPMC•Pittsburgh, PA

About The Position

The Trauma Registrar maintains the efficient operation of the Trauma Patient Registry and ensures consistency and quality in its data collection system. The role identifies trauma patients and admissions, abstracts, codes, and enters information into the trauma database, retrieves data for quality assurance, and supports compliance with Pennsylvania Trauma Systems Foundation (PTOS) data requests and submission timelines. The registrar works closely with the Trauma QA/Registry Coordinator and Trauma Program Manager and also interacts with Medical Records, Information Services personnel, and patient unit staff. The position involves maintaining accurate registry and statistical data, generating routine and requested reports, conducting concurrent record review, and supporting trauma quality improvement, research, education, outreach, and public relations activities. It requires maintaining patient confidentiality, following hospital information-security policies, and keeping current with relevant knowledge through in-services, seminars, and reference materials.

Requirements

High school diploma with a minimum of 3 years of trauma registry, coding, and/or abstracting experience; or graduation from an accredited record technician program or an associate degree with 1 year of trauma registry, coding, and/or abstracting experience.
Knowledge of medical record content, medical terminology, anatomy, and physiology.
Prior experience in ICD-9 coding.
Act 34 clearance.

Nice To Haves

Abbreviated Injury Scoring (AIS) knowledge or experience is desired.
Experience in computer data entry, databases, and data retrieval is desirable.

Responsibilities

Document data and time of attendance at continuing education programs.
Support the Trauma Program’s service management objectives and the hospital’s commitment to excellence in trauma patient care.
Perform related responsibilities as requested by the Trauma Program Manager.
Follow protocol for adding or removing patients from the database.
Identify trauma patients by monitoring Emergency Department and Admitting Department identification systems daily.
Perform additional medical-record abstracting or audit activities for quality assurance, research, education, or identification and correction of documentation deficiencies.
Engage in follow-up activity as appropriate.
Maintain the computerized registry system accurately, including entering data and making additions and corrections.
Contact the Trauma QA/Registry Coordinator for problem solving and clarification of clinical information.
Maintain the statistical database, generate routine monthly reports, and respond to special requests for statistical information.
Work with the Trauma Nurse Specialist and Trauma QA/Registry Coordinator to collect, organize, and disseminate results.
Maintain confidentiality of patient information and follow hospital information-security policies.
Ensure PTOS information is accurate, complete, and submitted within established time frames.
Communicate with the state Trauma Registrar and/or PTOS analysts to clarify information or respond to requests for clarification.
Maintain and expand knowledge through appropriate in-services, seminars, and reference materials.
Abstract relevant information from trauma patient medical records for the hospital registry and Pennsylvania Trauma Outcome Study, including selecting and coding diagnoses and procedures using ICD-9-CM and accurately calculating trauma and Injury Severity Scores.
Retrieve database information upon request from Trauma Services or other appropriate personnel, determine the required data elements, and design the output.
Attend and participate in Trauma QI activities, including MAC meetings.
Conduct concurrent review of trauma patient records within 48 hours of admission and enter selected information into the database for quality assurance, outreach, education, and public relations purposes.
Document and disseminate information as appropriate.