HIM Trauma Registrar

Overview

USA Health is transforming medicine along the Gulf Coast to meet the unique needs of the community. The organization provides advanced medical care, education, and research across multiple facilities, campuses, clinics, and classrooms in Mobile and the surrounding area.

Responsibilities

• Abide by all compliance requirements and policies and perform duties in an ethical manner consistent with organizational values.
• Adhere to hospital policies including confidentiality.
• Review emergency department registration and/or admission records daily to identify trauma admissions for entry into the trauma registry software.
• Screen death reports, inpatient and outpatient surgery records, and emergency records for trauma case identification.
• Review electronic medical records to assess information required for abstraction and quality improvement.
• Obtain core information from patient medical records and enter it into approved trauma registry software.
• Maintain confidentiality and security of patient data stored in the Trauma Registry.
• Code trauma-specific injuries and AIS scoring.
• Maintain quality control of case finding, abstracting, coding, and data processing procedures.
• Follow established procedures for manual and/or computer retrieval of trauma data.
• Answer requests for data as assigned.
• Prepare special and routine reports summarizing the hospital’s trauma experience.
• Compile patient care data from all phases of care for inclusion in the monthly Quality Improvement Program.
• Attend weekly trauma conferences and transcribe and maintain official minutes.
• Maintain accurate logs and reports.
• Use correct documentation tools and procedures.
• Perform concurrency rounding with the trauma team when applicable.
• Verify fax transmissions by reviewing fax logs.
• Communicate effectively with physicians, patients, families, and the healthcare team using in-person, phone, email, fax, and other communication methods.
• Relay unfinished requests and duties to incoming shifts.
• Send internal and external emails in a secure format.
• Complete all mandatory unit, educational, and hospital requirements.
• Use cost-effective practices in all aspects of the job.
• Adhere to the hospital-approved dress code.
• Comply with current infection control and safety standards.
• Maintain regular and prompt attendance.
• Work scheduled hours and overtime as required.
• Perform related duties as assigned.