Trauma Registrar II (#RH0240)
$26.13-$31.76 Hourly / $4,528.71-$5,504.67 Monthly / $54,344.52-$66,056.10 Yearly

Under general supervision, identifies and abstracts data from the medical records of trauma patients who visit San Joaquin General Hospital; maintains a data base of trauma-related information for quality assurance purposes and to meet the standards of the American College of Surgeons (ACS); retrieves data and prepares reports from the trauma data base system; and does related or other work as required in accordance with Rule 3, Section 3 of the Civil Services Rules.

This is the journey level in the Trauma Registrar series. An employee in this class independently performs the full range of technical duties associated with the development and maintenance of a trauma database for San Joaquin General Hospital.

This class is distinguished from the lower-level class of Trauma Registrar I as the latter is the entry-level class where incumbents receive training and learn to perform the full range of Trauma Registrar duties.

This class is flexibly staffed with the class of Trauma Registrar I, and incumbents are expected to promote from that class to Trauma Registrar II when they meet the minimum qualifications of the higher level and are preponderantly performing duties consistent with that class.

• Identifies all qualifying cases from the trauma patients brought into the hospital for inclusion in the registry, in accordance with ACS standards; updates previously included cases as needed; assembles chart copies as listed to complete abstractions.
• Identifies and abstracts data from patient medical records, including demographics, location of injury, and pre-hospital data, for the purpose of statistical reporting, analysis, and inclusion into the trauma registry; collects data and researches missing patient care documentation as needed from multiple sources, including other facilities or agencies.
• Maintains an electronic registry that adheres to reporting requirements and complies with prescribed standards and regulations needed for trauma center accreditation by the ACS Committee.
• Utilizes Abbreviated Injury Scale/Injury Severity Scores (AIS/ISS) and International Classification of Diseases (ICD9) codes to compile indicators and statistics for use by the Trauma Nursing Director, physicians, and other Hospital staff.
• Generates and prepares reports on trauma populations, performs data searches for trauma-related research projects, and provides information that will be used for Performance Improvement activities to facilitate continued education and system improvement.
• Maintains trauma and ambulance logs; reviews the logs for omissions and duplicates; provides log data to other departments (e.g., medical records) as appropriate.
• Prepares and submits periodic data reports of trauma cases and information to the Trauma Nursing Director, Emergency Medical Services (EMS), and/or other Hospital staff/departments as directed; prepares and submits reports to the National Trauma Data Bank, in accordance with ACS guidelines.
• Maintains confidentiality and security of all patient information in compliance with Hospital and federal regulations; maintains quality control of case findings, abstracting, coding, follow-up and data processing.
• Maintains records for continuing Quality Assurance indicators reviewed at periodic meetings.
• Participates in continuing education coursework to stay abreast of new developments in registry data management, regulations, requirements, and trends; assists in updating policies and procedures related to trauma registry activities as assigned.
• Provides general administrative assistance to the Trauma Nurse Director pertaining to the coordination of unit functions.
• Performs other or related duties as assigned.

Trauma registration practices and procedures; basic anatomy and physiology, disease processes, and medical diagnostic procedures; medical terminology applicable to pre-hospital care, emergency room care, and discharge care; general requirements associated with maintaining trauma registries and ensuring compliance with ACS standards; electronic data management and reporting, including the use of standard office software applications and Microsoft Excel; methods of researching and gathering medical information; various types of equipment, instruments and supplies used in an emergency room setting.

Accurately read and interpret handwritten and transcribed documents in a medical record, identify qualifying trauma cases, and abstract/code case information into a trauma registration data base; accurately type at a speed of approximately 40 words per minute; maintain strict confidentiality of information as required by Hospital policies and federal regulations; retrieve and maintain data and information in automated systems and documents; efficiently and effectively utilize standard office computer hardware and software including Microsoft Excel; understand and carry out instructions from medical, nursing and/or other staff; work under pressure and meet critical deadlines; accept changes in work assignments due to shifting priorities; work effectively as a member of a specialized team; communicate effectively, both orally and in writing; maintain cooperative relationships with those encountered during the course of the work.

Mobility - Constant sitting for long periods of time; frequent walking required; occasional pushing/pulling; occasional bending/squatting; occasional stair climbing. Lifting - Frequent lifting required of 5 lbs or less; occasional lifting required of 5 to 25 lbs. Vision - Constant reading, color perception, eye/hand coordination, depth perception, close up work and field of vision/peripheral. Hearing - Frequent hearing and talking in person and on the telephone. Dexterity - Constant keyboarding/typing, and manipulation of small objects; Emotional/Psychological - Constant concentration; frequent exposure to grief/trauma and emergency situations; frequent decision making; occasional potential for exposure to hazardous materials. Environmental Conditions - Constant work in an indoor environment; occasional loud noises.