The Clinical Data Registrar is responsible for the collection/abstraction of required data bank elements into the clinical program registry database on all patients meeting defined inclusion criteria. The Registrar maintains the confidentiality of the registry data and provides registry data as appropriate for performance monitoring and improvement and research.
- Performs basic data collection of demographics and coding of clinical and follow-up data from all sources into clinical program registry database.
- Interacts with physicians, nurses, and other members of the assigned clinical program team and patients to perform registry functions.
- Determines appropriateness of patient entry into the Clinical Program Registry based on the applicable clinical program guidelines and data standards/dictionary.
- Provides high quality data entry by abstraction of required data elements from the patient chart in real time and retrospectively.
- Participates in quality assurance, data validation (5-10% case files), and improvement activities to ensure accuracy of data collection and timely submission of data according to required standards within and/or across clinical programs as applicable to remain compliant with validation requirements.
- Understands mapping concepts and validates mapping of registry software for reporting requirements.
- Resolves routine coding issues/problems and appropriately seeks assistance from assigned Clinical Program leadership and/or Registry vendor when appropriate.
- Recognizes patterns of mechanism of injury during case abstraction in order to contribute to opportunities for injury prevention and community safety.
- Reports data in formats such as Excel and/or PowerPoint for both internal and external consumption (includes statistical, clinical, and research data).
- Assists with performance improvement projects under the direction of the Operations/Program Manager/Director as indicated.
- Maintains confidentiality of the registry and follows guidelines re: Data Request Management.
Accountabilities :
- Keeps registry current as per the Standards Set by the Regulatory Bodies, which is currently 80% complete within 60 days of patient discharge.
- Ensures data validation (5-10% case files) with a validity rate of not <90%.
- Completes required reporting in required timeframes.
- Responsible for the Trauma and/or Burn Program Data Registry
Required: Bachelor degree in health related field
Specialist Certifications:
Required:
Within one year of hire the following are required, if not already certified:
Recognized Registrar Certification or program
Injury Scaling Certification
ICD Coding Certification (current and maintain currency within 5 years)
Desired:
Certified Abbreviated Injury Scale Specialist (CAISS)
OR
Certified Specialist in Trauma Registries (CSTR)
Required Experience:
Work experience of at least two years and knowledge of medical terminology is essential
Proficiency in utilizing computer applications (Word, Excel, etc ) and data management
Desired :
Work experience of at least two years with strong emphasis on data integrity and analysis
Trauma/burn care experience
Previous Registry/Report Writing experience