Trauma Registrar -Orlando Regional Medical Center

Position Summary

Join a team dedicated to advancing trauma and burn patient care through data excellence, quality improvement, and meaningful healthcare outcomes. The Trauma Registrar I is responsible for the accurate identification, abstraction, coding, validation, and management of trauma and burn patient data within the Trauma and Burn Registries, ensuring compliance with American College of Surgeons (ACS), American Burn Association (ABA), state, and national reporting standards.

This role performs detailed medical record reviews and applies ICD-10-CM, Abbreviated Injury Scale (AIS) coding, Injury Severity Score (ISS), and burn-specific coding methodologies to capture comprehensive patient information across the continuum of care. A strong emphasis is placed on data integrity through rigorous quality assurance, validation, and audit processes to ensure the accuracy, completeness, and reliability of data submitted to state and national databases.

The Trauma Registrar I supports trauma and burn performance improvement, research, community outreach and prevention, benchmarking, and regulatory initiatives by maintaining high-quality registry data and generating reports for healthcare leaders and multidisciplinary teams. Success in this role requires advanced analytical skills, exceptional attention to detail, proficiency in medical terminology and coding principles, and the ability to prioritize workloads while meeting productivity and submission deadlines.

• Identifies trauma patients based on specific criteria, abstract complex clinical data, perform data entry, and calculate an accurate severity score within the trauma registry.
• Performs trauma related ICD-10 diagnostic coding and related procedure coding.
• Completes all aspects of Abbreviated Injury Scale coding.
• Analyzes and abstracts data with accuracy.
• Performs peer review audits for data validation.
• Maintains at least 95% validity on all critical data elements.
• Assures registry validity through frequent custom report review and registry utilities.
• Assures all data points of registry are properly completed and updated.
• Follows State guidelines to assure all essential elements are properly recorded.
• Maintains concurrent registry through daily abstraction on discharged clients and current admissions.
• Assures ongoing registry analysis for promotion of prevention activities, research, and injury/demographic reviews.
• Manages data according to the Orlando Health policies and guidelines.
• Assists with projects under the direction of the Manager, Clinical Specialty Data that support education, research, and trauma program.
• Assists with preparation for all trauma and burn site surveys. Collaborates with Department IS Consultant to ensure data integrity and validation as clinical resources.
• Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA, and other federal, state, and local standards.
• Maintains compliance with all Orlando Health policies and procedures.
• Completes all assignments within time requested.
• Team approach to complete daily, weekly, and monthly assignments.
• Utilizes critical thinking, problem-solving and process improvement concepts to create an efficient work environment.
• Self-directed to achieve team goals.
• Education/Training Collaborates with Trauma Registrars and Department IS Consultant to ensure data integrity and validation as clinical resources.

• Maintains open communication with Manager, Clinical Specialty Data, and Clinical Practice Improvement Consultant assigned to trauma regarding any concerning system or patient care issues noted during abstraction or data entry phase.

• Associate degree or higher; or completion of Trauma Registrar Course; or one year of direct trauma registry or ICD-10 coding experience.
• Knowledge of essential medical terminology related to trauma and emergency medical services.
• Proficient in MS Word, Excel, and Windows OS.
• Completion of AAAM’s Abbreviated Injury Scale Course, a Trauma Registry course, and ICD-10 within one year of hire.
• Current TNCC, 3 yrs clinical experience, BSN preferred, in lieu may have ASN with national certification.

Four (4) years in health-related field, with a strong emphasis on data integrity, abstraction, and analysis. Associate degree or higher, may substitute for two (2) years of experience.