The Trauma Registrar is responsible to maintain efficient operation of the trauma patient registry. The registrar ensures consistency and quality in the trauma patient data collection system maintaining compliance with the Pennsylvania Trauma Systems Foundation (PTSF) and American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) requests for data. Job Responsibilities 1. Abstracts from the trauma patient medical record relevant information required for the hospital registry and the Pennsylvania Trauma Outcome Study (PTOS), including selection and coding of diagnoses and procedures using ICD10-CM/ ICD 10/PCS, calculation of trauma and Injury Severity Scores (TRIS/ISS), and TQIP and National Trauma Data Bank (NTDB). • Ensure that all of the PTOS information is accurate, complete, and submitted within the time frames established by PTSF in PTOS manual. This is done by maintaining communications with PTSF Trauma Registry for purposes of clarifying information or respond to requests for clarification of information. • Perform additional trauma patient medical record abstracting or audit activities for quality assurance, research, education, or for the purpose of identifying and addressing documentation deficiencies. • Works collaboratively with the Trauma Program Medical Director, Trauma Program Manager, and the Trauma Program Performance Improvement Coordinator, and other trauma colleagues to collect, organize, and disseminate results. • Perform additional trauma patient medical record abstracting or audit activities for quality assurance, research, education, or for the purpose of identifying and addressing documentation deficiencies. • Participates in the Interrater Reliability (IRR) program • Maintains and monitors Trauma Registry Log to ensure accuracy and timeliness. 2. Assists with compliance with PTSF standards and other applicable regulatory standards • Remains knowledgeable concerning pertinent PTSF standards, Trauma Registry guidelines and other standards pertinent to this area. • Assists with preparation for PTSF site surveys. • Assists with maintaining Trauma policies and procedures 3. Serves as an active member of trauma specific committees internally and externally and contributes to system and programmatic development and planning. • Attends internal Trauma related committees when appropriate. • Stays abreast of current national trauma rules, regulations and trends • Attends pertinent external trauma conferences • Participates in national, state and local committees when appropriate. Required Licenses, Certifications, Registrations Required Education and Experience Required Education: High School diploma Required Experience: Medical terminology and anatomy and physiology knowledge required Preferred Education, Experience, Licenses and/or Certifications Preferred Education: Associate’s Degree in a health related field Preferred Experience: • At least two (2) years of medical coding or abstracting experience • Trauma Registry experience • ICD-10-CM/ICD-10-PCS coding and ISS coding knowledge Preferred Licenses/certificates/registrations: • Completion of Abbreviated Injury Scoring (AIS) Course • Completion of ATS Trauma Registrar Course OR • Completion of PTSF Basic Trauma Registrar Course • TQIP training course Willing to take required courses within 1 year of hire.