Coder/Abstractor (Trauma Registrar)

Job Description

The Coder/Abstractor is responsible for ensuring that timely, accurate, and complete data is collected and maintained on all severely injured patients according to the guidelines of University Hospital'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, and special projects ? as assigned.

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-10-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 daily, identifies expired trauma patients, and enters data into the trauma registry. Obtains trauma patient autopsy reports from the coroner and enters data into the registry. - 5%
• Performs statistical analysis of data for reporting, performance improvement, and maintenance of Level I trauma verification status. - 10%
• Participates in ongoing clinical trauma research programs. - 5%
• Assists the Trauma Program Manager, Trauma Medical Director, and Trauma Information Coordinator with trauma registry responsibilities. Performs other duties as assigned. - 5%
• Concurrent identification of trauma quality improvement filters. Maintains confidentiality of patient information. - 10%

Physical Demands

• 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 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: 0%
• Pushing 11-20 lbs: 0%
• Pushing 21-50 lbs: 5%
• Pushing 51 lbs or more: 0%
• Pulling: 0%
• Lifting 0-10 lbs: 5%
• Lifting 11-20 lbs: 0%
• Lifting 21-50 lbs: 0%
• Lifting 51 lbs or more: 0%
• Carrying 0-10 lbs: 5%
• Carrying 11-20 lbs: 0%
• Carrying 21-50 lbs: 0%
• Carrying 51 lbs or more: 0%
• Fingering: Picking, pinching, typing or otherwise working primarily with fingers - 30%
• Feeling: 0%
• Talking: Expressing or exchanging ideas verbally, must convey detailed or spoken instructions - 5%
• Hearing: Perceiving sounds at normal speaking levels, ability to receive detailed information - 5%
• Seeing: Visual acuity requirements include ability to discern position, shape, color, depth, or visual inspection - 30%

Qualifications

Minimum Required: High School Diploma or GED | Preferred: CPC, CCS, RHIT, RHIA, CSTR, CAISS | Preferred: 7 - 11 Months equivalent experience