Abstractor - League City Trauma Services

EDUCATION & EXPERIENCE 

Minimum Qualifications\: 

• High school or equivalent 
• Two years of directly related EMR experience

JOB DESCRIPTION

To provide coordination of data collection and data entry on specific patient populations as directed by the department manager.

Scope/Function:

To provide coordination of data collection and data entry on specific patient populations as directed by the department manager.

ESSENTIAL JOB FUNCTIONS

· Reviews daily admission reports to identify patients for appropriateness of inclusion criteria into the registry based on criteria defined by the credentialing agency.

· Performs concurrent and retrospective review of the medical record to extrapolate key data elements from pre-hospital provider, emergency department, inpatient and operative notes.

· Enters assigned data points identified by the department manager into the registry.

· Reviews electronic medical record and enters appropriate data into the registry.

· Complies and enters data into the registry that is relevant to patient care in all phases of care (i.e., pre-hospital, emergency department, acute in-patient care, and rehabilitation).

· Coordinates the collection of data for reporting to the state and/or national registries.

· Demonstrates knowledge of procedures necessary for developing and maintaining a comprehensive records management system.

· Communicates written and/or verbal registry information to the department manager as necessary to meet the goals of the program.

· Protects confidentiality of patient information at all times.

· Adheres to internal controls and reporting structure.

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a Federal Contractor, UTMB Health takes affirmative action to hire and advance protected veterans and individuals with disabilities.