Trauma Registry Abstractor Requirements

Department: Data Abstractors

Division/Location: Direct Difference – Support of contracted facility as designated

Skill Set: Clinical Data Abstractor – Trauma Registry

Job Summary/Purpose:

Performs clinical auditing and data abstraction of patient records in support of contracted facility’s clinical process improvement and patient safety initiatives associated with participation in. Results of audits and identified trends are reviewed with Clinical Nurse Specialists, unit-assigned clinical staff, Performance Improvement staff, and physician quality task forces.

Minimum Qualifications:

Education: Graduation from an accredited school of nursing as an LPN or an RN
Experience: At least 3 years of acute care nursing experience
Licensure: Must be licensed by State Board of Nursing 

Other Preferred: Certified Tumor Registrar, completion of NCRA certification exam :

  • Must have a minimum of 2 years recent experience abstracting Trauma Registry, CSTR Preferred
  • Must maintain competency and knowledge of data definitions and reporting guidelines.
  • Must possess knowledge of anatomy and disease processes.
  • Must be computer literate and knowledgeable in spreadsheet software, database programs, Microsoft Office software.
  • Requires flexibility in work schedule.

Job Description

  • The Data Abstractor’s key responsibility is to collect and submit accurate, complete, and timely data for Trauma Registry. This task is accomplished through high-quality data compilation, documentation, and data entry of identified procedures performed at the Center into the associated registry/vendor tool platform.

Specific Responsibilities and Capabilities 

  1. Data Collection and Reporting
    • Reviews 100 percent of Trauma Registry patients for inclusion in the Trauma Registry as identified by the facility.
    • Collects pre-arrival/EMS associated data as well as data associated with the encounter to include but not limited to the following:  details associated with presenting trauma, co morbid conditions, preoperative, intraoperative, and postoperative follow-up data components for the program through the effective utilization of the hospital medical record systems.
    • Identifies streamlining and process improvement opportunities in the data collection process.
    • Responsible for the accurate, complete, and timely entry of data into the program’s database.
    • Maintain accuracy threshold of greater than or equal to 95 percent.
  1. Work Effectively with Hospital and Individual Surgeon Office Staff 
    • Serves as an educational resource on the Trauma Registry for internal and external audiences as needed.
    • Clearly communicate any data documentation needs to support accurate and high reliable data collection and reporting.

Primary Requirements

  • Participates in program teleconferences.
  • Participates in data compilation for audits and (re)accreditation or site visits.
  • Periodically attends voluntary in-person professional development seminars offered at various annual meetings such as ATS and ACS.

Data Registry

Direct Difference supports accurate, reliable data abstraction of clinical data registries. Our commitment is excellence.

Core Measures &
Data Abstraction

We have been abstracting and supporting core measure abstraction since its inception. We offer unparalleled expertise.

Medical Records
Research/Peer Review

Ask us about our customized processes for OPPE and FPPE reviews for Emergency, Medical, Surgical, Anesthesia Services.

Technology & Software

We’re an effective and efficient partner, with extensive affiliations and support for specialized technology and software.