Job Summary: Trauma Registrar is responsible for collecting, abstracting, coding and reporting data regarding patients with traumatic injuries.  The incumbent reviews medical records and communicates with trauma team staff to identify reportable cases and to collect information related to severity and cause of injury and course of care and outcome, and codes and enters the data into the New York State Trauma Registry database according to program guidelines. 

Responsibilities:

• Reviews a variety of medical records to collect information related to trauma patients
• Identifies patient records that meet criteria for inclusion in the New York State Trauma Registry, using ICD diagnosis and other criteria defined by the Registry
• Reads and interprets the various components of the medical record, such as physician documentation, radiology reports, laboratory reports and all treatment modalities, in order to abstract and code for entry into the Trauma Registry Database
• Prepares an exclusion report for the Trauma Registry when appropriate
• Research additional information not given in medical records by, for example, contacting other physicians or institutions.
• Obtains follow-up information for entry into database
• Maintains the components of the trauma-related data collection system consistent with all regulatory and procedural policies
• Performs quality control activities and ensures accuracy of data
• Runs, compiles and distributes a variety of routine and specialized reports for hospital administration and staff
• Participates in all functions related to the Trauma Registry, as required.

Qualifications/Requirements:

Experience: Experience in healthcare and/or health information coding, along with a combination of education, training and experience that has supplied the necessary knowledge, skills and experience to perform the essential functions of the job, required.

Education:  High school or equivalency diploma, required, Associates or Bachelor’s degree preferred.

Licenses / Certifications:  CPC, CSTR ,CAISS preferred.

Other: 

Special Requirements: Knowledge and understanding of the guidelines of the New York State Trauma Registry for trauma abstracting. Knowledge of medical terminology; good knowledge of the ICD codes; ability to read, understand and apply the appropriate guidelines for trauma abstracting; ability to accurately abstract and stage information from the various components of patient medical records; ability to understand and code medical records.