|
| Job
Code: |
1321
|
| Job
Title: |
Trauma
Abstractor
|
| Creation
Date: |
05/01/94
|
|
| Revision
Date: |
08/02/02
|
| FLSA
Status: |
Non-Exempt |
Job Summary:
To provide coordination of data collection and data entry for trauma patients into the trauma registry as directed by the Trauma Registrar.
Major Duties / Critical Tasks:
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Calculates Glascow Coma Score and Trauma Score from medical documentation when necessary.
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Using American Association of Automotive (AAAM) Scoring System, calculates the Injury Severity Score which is derived from Abbreviate Injury Score
(AIS) and Injury Severity Score (ISS) on patients entered into the Registry.
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Reviews Emergency Department register and/or admission records daily to identify trauma admissions for entry into trauma registry. Screens multiple computer printouts, ED Trauma Log Book, and autopsy reports obtained from Medical Examiner for trauma patient information.
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Abstracts relevant information such as professional services rendered (admissions, daily care, tests, producers, consultation, discharges) and diagnoses provided.
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Maintains a daily log of the number of patients admitted, discharged and transferred in or out, submitted for review and billing, and on hand at the end of each day.
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Acquires patient records of all patients identified post-discharge for review, analysis, and entry into Trauma Registry. Reviews records for data collection and quality improvement according to standards outlined by the Trauma
Committee and as directed by the Trauma Registrar.
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Abstracts pertinent data onto trauma registry abstract sheet for entry into the database management program activities/projects, as directed by the Trauma Registrar.
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Complies data relative to patient care in all phases of care (i.e., pre-hospital, emergency department, acute in-patient care, and rehabilitation) for inclusion into the monthly Quality Improvement Report as needed.
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Coordinates the collection of data for reporting to national registries, including but not limited to, the Major Trauma Outcome Study, Spinal Cord and Head Injury Registry, JCAHO,
TDH, ACS, and as directed by the Trauma Registrar.
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Demonstrates knowledge of procedures necessary for developing and maintaining a Trauma database records management system.
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To ensure accuracy, evaluates appropriateness of ICD-9/CM codes as needed.
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Communicates written and/or verbal registry information to Trauma Registrars, Trauma Case Manager, and/or Trauma Director as necessary to meet the goals of the program, while maintaining confidentiality.
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Adheres to internal controls established for department.
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Performs related duties as required.
Required Education / Experience:
High school or equivalent and two years quality assurance experience.
Equipment:
Standard office equipment.
Working Environment:
Standard office environment.
Other:
Specific job requirements or physical location of some positions allocated to
this classification, may render this position security sensitive, and thereby
subject to the provisions of Section 51.215, Texas Education Code.
Any
qualifications to be considered as equivalents in lieu of stated minimums
require the prior approval of the Chief Human Resources Officer.
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