Responsibilities

The Trauma Registered Nurse Registrar holds a current Pennsylvania nursing license as a Registered Nurse. Responsible for reviewing, interpreting and analyzing the Trauma patient's medical record for abstraction into the state-required Trauma Registry of patients meeting inclusion criteria defined by the Pennsylvania Trauma Systems Foundation's (PTSF) Operational Manual for the Database Collection System, National Trauma Data Standard data dictionaries and Grand View Health criteria. Maintains and protects the integrity of the Trauma Registry database, data management, data analysis, report writing and statistical and graphic output of trauma data.
Essential Functions:

• Performs concurrent Trauma record abstraction and interprets the clinical data in the record for accurate entry into the Trauma database in a timely manner. Maintains confidentiality and security of all patient data in the Trauma Registry.
• Ensures data entry is accurate, complete and conforms to the Pennsylvania Trauma Systems Foundation's (PTSF) Operational Manual for the Database Collection System and National Trauma Data Standard data dictionaries definitions. Accurately utilizes Tricode software in the PTSF Trauma Registry, ensuring accurate injury coding of AIS, TRISS and ICD-10 codes. Utilizes additional resources, manuals, ICD-10 CM Diagnosis and procedure coding books, and Abbreviated Injury Scale scoring book by the Association for the Advancement of Automotive Medicine. Submission of PTOS patient data via the Pennsylvania Trauma Systems Foundation's portal within 42 days of discharge.
• Analyzes patient medical records according to established PTSF and GVH criteria for inclusion in the Trauma Registry database. In collaboration with the PIPS, RN accurately and efficiently identifies PTSF qualifiers and audit filters.
• Assists the Trauma PIPS Coordinator/Trauma Program Manager with data collection and performance improvement activities as assigned.
• Functions as an important resource to plan, identify, trend, analyze and integrate new data collection elements for use in Trauma patient care management, performance improvement and statistical and research purposes. Proficient in report-writing skills while utilizing Trauma Registry data.
• In collaboration with Trauma Program Manager, ensures the integrity of the system with timely updates, enhancements and system back-up. Is able to independently troubleshoot hardware and software system problems as they arise.
• Completes required Trauma Registrar education in the time frames as defined under EDUCATION AND CERTIFICATIONS.
• Completes 8 hours of trauma-related education annually (calendar year) as defined by the PTSF.
• Attends Trauma Program Multidisciplinary meeting with attendance of 50% of all meetings held and other meetings as assigned.