Description
Performs clinical data abstraction of patient records in support of the contracted facility’s clinical process improvement associated with participation in a State or National Trauma registry. The ideal candidate will have a comprehensive understanding of trauma registry systems, be highly organized, and have excellent communication skills.
Responsibilities
• Identify and compile patient data from a variety of relevant sources.
• Organize and enter trauma data into the trauma registry database regarding the patients’ injury event, severity, care, and outcome.
• Abstract appropriate data elements for all trauma patients, ensuring all necessary elements are captured.
• Establish the injury severity score using AIS methodology and injury procedures and diagnosis using ICD-10 methodology.
• Participates in quality assurance processes to ensure data integrity. This involves regular audits of the data or the abstraction process.
• Remains informed about developments in trauma care and data management to ensure ongoing competency in the role.
Qualifications
• Trauma abstraction experience preferred.
• Excellent interpersonal communication and documentation skills.
• Strong attention to detail.
• Ability to work independently.
• Proficient in Microsoft Office.
• Documentation of completion of the Trauma Registry Course is required.
• Documentation of completion of the AAAM AIS Coding Course is required.
• Documentation of completion of the ICD-10 course certificate (within the last 5 years).
• Certified Specialists in Trauma Registries (CSTR) is preferred.
