Responsible for all aspects of the trauma registry and coordination of trauma performance improvement and patient safety processes. Responsible for the identification of all patients meeting trauma registry inclusion criteria and completion of data abstraction from all phases of the patients care into the trauma registry. The lead Trauma Nurse Registrar/Data Analyst is to oversee the daily operations and maintenance of the trauma registry, performing data analysis, project development, and preparation of reports. The lead Trauma Nurse Registrar/Data Analyst will collaborate with physicians, nurse practitioners, consultants and multidisciplinary trauma team members to assure quality patient outcomes across the continuum of care as well as collaborates closely with Trauma Program leadership to assure compliance with trauma standards and guidelines. 

MAJOR ACCOUNTABILITIES / SPECIFIC JOB COMPETENCIES

Completes concurrent chart review/case review while maintaining the tracking system for all cases, case reviews, quality indicators, and reports. Documents all action and loop closure in the registry. Participates in Trauma Performance Improvement Committee (TPIC) and Trauma Operations Committee (TOPS). Submits timely data dashboard reports and QI reports. Participates in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) by ensuring accurate data entry, timely data submission, accuracy review of TQIP validation reports, and participation in conference calls and webinars. Reviews clinical incidents in collaboration with the PI Coordinator, Trauma Program Manager, and Trauma Medical Director, initiating appropriate actions on all identified issues. Participates in system PI locally, regionally and nationally. Assists with the development of policy and/or evidence based guidelines, including the assurance with compliance. 

  Correctly identifies trauma patients for entry into the trauma registry from all sources of entry into the hospital. Abstracts appropriate data from the medical record into the trauma registry, and completes and verifies all data for accuracy. Works collaboratively with all members of the trauma registry staff toward concurrency in the trauma registry according to American College of Surgeons (ACS) standards. Actively participates in data validation activities. Accurately assigns and scores all injuries in the trauma registry, utilizing the Abbreviated Injury Scale (AIS) and ICD-10 system. Utilizes all parts of the medical record to abstract patient data, as well as process and outcome data, across the care continuum as defined by the trauma quality program. Accurately assigns E-codes and collects and codes data on all procedures and complications. 

  Demonstrates ability in report writing and generation. Prepares monthly, quarterly, annual and ad-hoc reports as requested by trauma administration for the purpose of quality improvement and the trauma research program. 

  Actively participates in all audits, site surveys, and other special events as directed by the TPM and Trauma Medical Director (TMD). Participates in hospital, local, regional, state and national trauma data, educational, injury prevention, and research activities as directed by the TPM and TMD.

LEVEL OF EDUCATION

AA Degree in Nursing BSN preferred.

CERTIFICATIONS, LICENSES, REGISTRATIONS 

Current Registered Nurse in California ACLS and BLS from the American Heart Association (AHA) PALS from the American Heart Association or Emergency Nurses Pediatric Course (ENPC) certified.  Trauma Nursing Core Course (TNCC) or Advanced Trauma Care for Nurses (ATCN) certified preferred Certified Specialist in Trauma Registries (CSTR) by American Trauma Society preferred

TECHNICAL REQUIREMENTS

Clinical expertise in the practice of trauma nursing. Intermediate MS Word and Excel skills. Experience with coding, ICD-10, AIS coding systems, registry database, and/or statistical software (SPSS, STATA) preferred

YEARS OF RELATED WORK EXPERIENCE 

2 years of experience in trauma nursing, including experience in quality assurance 5 years of experience in trauma nursing, teaching, and quality assurance preferred 1-5 years working as a Trauma Registrar or with medical coding experience preferred