Trauma Registry Nurse

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The Registry Nurse is responsible for concurrent and retrospective data abstraction from patients' charts and its entry into the trauma registry. This position is essential to the trauma program and to the organization at large to enable the organization to have accurate and timely data to support injury prevention efforts, organizational research, and quality improvement activities. The Registry Nurse ensures that data abstraction and entry into the registry is accurate and correctly reflects patients' injuries, procedures, studies, and hospital events in the course of hospitalization, as determined by the National Trauma Data Standards, and internal organizational requirements/dictionaries. The Registry Nurse collaborates with trauma program stakeholders to determine the full extent of injuries and complications for a selected specific patient population. The Registry Nurse will assist trauma program leadership in maintaining the integrity of the registry, generate queries and reports, and ensure compliance with all HIPAA regulations. Adheres to the "I Am YNHH" service excellence pledge and promotes a positive work environment.

EEO/AA/Disability/Veteran

1. Abstracts the required data from the medical record and other available concurrent sources.

1.1 Identifies the appropriate inclusion and exclusion criteria for patients to be included in the Trauma Registry.

2. Facilitates and maintains a streamlined flow of data into registries.

2.1 Functions within the department's administrative guidelines for workflow.

2.2 Works effectively with Trauma Data Coordinator to facilitate data flow within the registry and support patient capture for the trauma registry.

2.3 Reports critical gaps in the medical record documentation to department leadership.

2.4 Maintains confidentiality of patient information according to institution policy and procedure.

3. Works to maximum efficiency in abstracting appropriate and necessary data for registry, while meeting the expected data entry deadlines.

3.1 Completes cases in according to workflow guidelines

3.2 Submits completed cases according to workflow guidelines.

3.3 Collaborates with team to complete monthly caseload in timely manner.

4. Maintains established data abstraction accuracy as determined by program data quality plan. Contributes to the data quality process.

4.1 Includes data from time of injury through rehabilitation.

4.2 Assures trauma registry assignment of injury type and severity accurately reflects patient clinical status.

4.3 Remains responsible for validating pre-populated data into the Trauma Registry.

5. Collaborates in a professional manner with trauma stakeholders to maintain goals and objectives of the registry as an integral part of the trauma program.

5.1 Effectively communicates gaps in documentation

5.2 Supports the processes of all members of the Trauma Department.

5.3 Demonstrates effective written and oral communication with all stakeholders

6. Professional Development

6.1 Participates in departmental staff meetings to remain current with issues, trends, and practices.

6.2 Attends inservices and conference to maintain adequate continuing education hours, as governed by external requirements. 6.3 Completes requisite training required by role.

EDUCATION

Registered Nurse - Graduating from an accredited school of nursing and possession of a current license in the State of Connecticut.

EXPERIENCE

3-5years nursing experience.

LICENSURE

Current CT RN license.

SPECIAL SKILLS

Excellent communication, negotiation and organizational skills. Excellent clinical judgment. Excellent knowledge of personal computers and related software. Adaptability to a wide variety of professional interactions. Comprehensive understanding in the use of medical records to extract data. Understanding of the use coding and scoring systems appropriate to the registry. Maintains and passes the appropriate registry specific performance measurements as required for the program.

PHYSICAL DEMAND

May require prolonged sitting, and prolonged use of computer.