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 specific registry. This position is essential to the Section of Trauma and Surgical Critical Care and to the organization at large to enable the organization to have accurate and up to date data to support 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, complications and events in the general course of hospitalization. The Registry Nurse collaborates with care coordinators, physicians, nurses and other health care professionals to determine the full extent of injuries and complications for a selected specific patient population. The Registry Nurse will assist Management and Coordinators to maintain the integrity of the specific 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.
Responsibilities: 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 administrative guidelines for department workflow.
2.2 Works effectively with Data Coordinator to facilitate data flow within the 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 15th of the month data entry deadline.
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. Has 94.5% accuracy on all data abstractions and data entry into data base as noted in department audits of work product.
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 all healthcare team members to maintain goals and objectives of the specific registry the Trauma Data Registrar supports.
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 in-services and conference to maintain adequate continuing education hours, as governed by external requirements.
6.3 Completes requisite training required by role.
Registered Nurse or Licensed Practical Nurse. Graduation from an accredited school of nursing and possession of a current license in the State of Connecticut.
3-5 years clinical experience in nursing field. Must be facile in use of electronic health record. Trauma registry experience preferred. Experience with computer data entry preferred. Experience with ICD-9 and ICD-10 coding preferred. Experience with Abbreviated Injury Scale preferred. May require walking in between office and campus locations.
Current CT RN or LPN License
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 specific registry. Maintains and passes the appropriate registry specific performance measurements for each program.
Responsible for accurate data abstraction and entry into the registry. Together with the manager of the specific registry is responsible for the selection of diagnosis and procedures and appropriate codes; determination of correct principal diagnosis and procedure, correct ICD-9/ICD-10, DRG, and APC assignment. Assist the Data Coordinator to audit inpatient and outpatient coding and documentation compliance. The LPN shall provide nursing care only under the supervision of the RN, as defined by the Nurse Practice Act, and State Board of Nursing.
Exercises independent judgment in determining appropriate diagnostic and procedural data from all types of medical record documentation and physician communication. Accountable to outside regulatory bodies for accuracy of the specific registry.
May require prolonged sitting, and prolonged use of computer.