Coder/Abstractor

Job Description

The Trauma Coder/Abstractor (Trauma Registrar) is responsible for ensuring that timely, accurate, and complete data is collected and maintained on all severely injured patients according to the guidelines of the University of Cincinnati Medical Center's Trauma Registry, the American College of Surgeons Committee on Trauma, the Ohio Trauma Registry, and the Tri-State Trauma Coalition. Tasks include basic case identification, review and abstraction of medical data from the electronic medical record, ICD-10-CM coding and Abbreviated Injury Scale (AIS) scoring of medical information, data entry, identification of quality improvement filters, generation of reports, data validation, and special projects as assigned.
  • Obtains, abstracts, and enters all appropriate patient-related information into the appropriate databases in an accurate and timely manner by:
    • Obtaining information by monitoring daily trauma patient admissions, transfers, and discharges, and confirming all patients and patient changes on the registry, autopsy, and patient identification logs.
  • Coordinating the collection of data from various sources, including but not limited to EPIC and its integrated medical record contents, EMS run report databases, and the coroner.
  • Analysis and entering appropriate data into registries, including entering all patients from the patient identification reports into the registry.
  • Requesting and entering autopsy report data.
  • Reports 300+ data elements, including complications, comorbidities, and the TQIP Measures of Processes of Care per the National Trauma Data Standard's definitions and criteria.
  • Ensuring that data is abstracted to meet data deadlines for the UCHealth trauma and hospital quality committees, the American College of Surgeons (ACS) National Trauma Data Bank registry, the Ohio Trauma Acute Care registry, the Tri-State Trauma Coalition, and the American Burn Association.
  • Participates in ongoing clinical research program's data collection.
  • Achieving and maintaining a validation accuracy rate of 90% or higher.


Responsibilities

Properly identifies trauma patients for inclusion into the trauma registry. - 10% � Analyzes and abstracts patient data from the electronic patient record. Inputs data into the trauma registry software program. Maintains consistency and quality of trauma data collection for continuous quality improvement and research purposes. - 40% � Codes all injuries by assigning an ICD-9-CM diagnosis code and scores all injuries by assigning an Abbreviated Injury Severity score based upon knowledge of rules established by the American Association for the Advancement of Automotive Medicine (AAAM). - 10% � Reviews the Expired Patient reports on a daily basis and properly identifies expired trauma patients and enters the data into the trauma registry. Obtains trauma patient autopsy reports from the coroner and enters data into registry. - 5% � Performs statistical analysis of data for reporting, performance improvement, as well as, continual preparation and maintenance of Level I trauma verification status. - 10% � Participates in ongoing clinical trauma research programs. - 5% � Assists the Trauma Program Manager, the Trauma Medical Director, and the Trauma Information Coordinator with related trauma registry responsibilities. Performs other duties as assigned. - 5% � Responsible for re-stocking the ED forms cart in the Trauma Resuscitation Units with trauma department forms. Retrieves the pink/yellow copy of completed Trauma H&P�s from the ED forms cart. - 5% � Concurrent Identification of trauma quality improvement filters. Maintains confidentiality of patient information. - 10% | Review the physical demands and assign an overall average percentage of time this position performs these activities. These physical demands will not be listed or rated on the annual performance appraisal. Climbing:�Ascending or descending stairs, ladders, ramps, etc, using feet and legs and /or hands and arms - 5% Stooping:�Bending body downward and forward by bending spine at the waist - 5% Kneeling:�Bending legs at knees to come to a rest on knee or knees - 5% Reaching:�Extending hand(s) and arm(s) in any direction - 10% Standing: Remaining upright on the feet, particularly for sustained periods of time - 5% Walking:�Moving about on foot to accomplish tasks - 5% Pushing 0-10 lbs:�Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 0% Pushing 11-20 lbs: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 0% Pushing 21-50 lbs: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 5% Pushing 51 lbs or more: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 0% Pulling: Use of upper extremities to exert force in order to drag, haul or tug objects in a sustained motion - 0% Lifting 0-10 lbs: Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 5% Lifting 11-20 lbs: Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 0% Lifting 21-50 lbs: Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 0% Lifting 51 lbs or more: Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 0% Carrying 0-10 lbs: Holding and moving/transporting an object about - 5% Carrying 11-20 lbs: Holding and moving/transporting an object about - 0% Carrying 21-50 lbs: Holding and moving/transporting an object about - 0% Carrying 51 lbs or more: Holding and moving/transporting an object about - 0% Fingering: Picking, pinching, typing or otherwise working primarily with fingers rather than with the whole hand or arm, as in handling - 30% Feeling: Perceiving attributes of objects such as size, shape, temperature or texture by touching with skin, particularly that of (using) fingertips - 0% Talking: Expressing or exchanging ideas by means of the spoken word - must convey detailed or spoken instructions to others accurately, loudly or quickly - 5% Hearing: Perceiving the nature of sounds at normal speaking levels with or without correction, and having the ability to receive detailed information through oral communication - 5% Seeing: The process of perceiving objects by use of the eyes to perform an activity - visual acuity requirements include ability to discern position of object(s), shape of object(s), color, depth perception or visual inspection - 30%

Qualifications

Minimum Required: Associate's degree or higher in Health Information Management or another health-related discipline; or 2 years of trauma registry experience