Summary:

The Clinical Quality Data registrar's chief responsibility is to collect and submit reliable and accurate data to registries that require a clinical background and knowledge base to abstract information for accurate data collection. This is accomplished through high quality data compilation, documentation and entry into databases/registries for the hospital. The registrar works closely with the members of the Medical Staff, Clinical Departments and the Department of Quality to identify opportunities for clinical quality improvement and other special projects as may be identified.

Responsibilities:

• Abstracts data for registries from medical records by scrutinizing a variety of sources including but not limited to physician notes/orders, history and physical, medication administration records, operative/procedure notes and nursing notes; works with member of the Medical Staff as needed; enters accurate information into the reporting systems; uses critical thinking skills to determine the relevance of available data to abstraction guidelines; independently pursues additional avenues of research to collect data in accordance with Center for Medicare and Medicaid Services guidelines.
• Completes record abstractions and focused reviews within timeframes as established by departmental goals and submission guidelines mandated by various agencies and registries; abstracts qualifying health records to ensure appropriate data collection in accordance with YRMC policies and procedures as well as meeting accreditation standards and State and Federal data submission; follows all HIPAA requirements and rules of privacy, maintaining and ensuring confidentiality protection when reviewing patient records.
• Enters abstraction information into the appropriate databases to permit data aggregation and statistical analysis.
• Identifies patients for inclusion in the program through the application of program inclusion/exclusion criteria and protocols; collects preoperative, operative, and postoperative data components for the program through the effective utilization of the hospital medical record systems; demonstrates applicability of the methodology and the reliability of definitions utilized by reviewers; demonstrates appropriate utilization of resources necessary to obtain valid, reliable data for entry into the program.
• Utilizes software applications for data collection and analysis; enters data into the program's database and meets the caseload accrual requirement protocol; reviews site accrual report on the database and responds to accrual report alerts; maintains a 2-5% error rate which is established on the total number of charts abstracted per year and the number of errors identified.
• Prepares documents in an organized, accurate, legible, and confidential manner to include follow up if deemed necessary; demonstrates an understanding of the organizational implications and responsibilities related to accurate data abstraction requirements in order to meet quality standards; Identifies streamlining and process improvement opportunities in the data collection process.
• Conducts interviews with patients to verify quality and safety processes; interviews and observes staff practices to measure compliance with established quality and safety processes.
• Other duties as assigned.

Requirements:

Associates Degree: Nursing

RN License

1+ YOE

Work Schedule: 8-hours, Days, Monday through Friday

Physical Requirements and working conditions for this position will be provided to you upon interview.