General Description:

The Trauma Registrar is responsible for reviewing and analyzing data within the medical record and trauma care reports reflecting health care provided to patients to ensure comprehensive quality care and identification of performance gaps.

Essential Responsibilities:

Responsibilities listed in this section are core to the position.  Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position. 

• Has working knowledge of the American College of Surgeons and Oklahoma State Department of Health inclusion criteria and ability to review reports and/or charts for possible candidates and select qualifying patients

• Accurately Codes and reports treatment of cases using the current International Classification of Diseases (ICD-10 CM) and Abbreviated Injury Scale (AIS) Coding

• Reviews care provided and identifies variations in the process or outcome of care provided

• Responsible for the data management, case findings, abstracting, data retrieval and analysis

• Ensures that all functions of the registry are met using the guidelines set forth by the American College of Surgeons, the National Trauma Data Bank (NTDB), and the Trauma Quality Improvement Program (TQIP)

• Reports statistics to physicians, administration and outside agencies upon requests

• Assist with information regarding the Trauma Registry

• Meets established guidelines for record completion in the Trauma Registry

• Participates in inter-rater validation of abstracted patient records

General Responsibilities:

• Performs other duties as assigned

Minimum Qualifications:

Education: High School Diploma or GED required.

Experience: 0-3 years of experience required. Experience in coding, abstracting data, or emergency room activities preferred. (Fully remote positions require a minimum of one (1) year trauma registrar experience.)

License(s)/Certification(s)/Registration(s) Required:   Must have previously attended, or attend within 2 years of hire the following courses:  The American Trauma Society’s Trauma Registrar Course or equivalent provided by a state trauma program, The Association of the Advancement of Automotive Medicine’s Injury Scaling Course, and ICD-10 Coding Course or standards as set forth by the American College of Surgeons.  Effective September 2023, ICD-10 Coding Course will be renewed every 5 years.

Knowledge, Skills and Abilities:  

• Understanding of Medical Terminology required. Utilization of Electronic Medical Records.

• Knowledge of principles and practices of trauma registry and medical records and policies and procedures. 

• Knowledge of indexing, classification and staging systems.

• Will need to know medical terminology, anatomy and physiology pertaining to trauma processes. 

• Database management skills, especially in abstracting and coding trauma related data from medical records and laboratory reports that are computerized. 

• Knowledge of report writing. 

• Good computer and interpersonal skills.