My First Week As A Trauma Registrar
TLDRThe speaker discusses their upcoming role as a trauma registrar, expressing curiosity about the coding process for ICD-10-CM and ICD-10-PCS, the assignment of external cause codes, and the inclusion criteria for trauma cases. They share their first week's experience, including orientation, learning the trauma registry process, and the use of the state registry program. The speaker is excited about the case-finding aspect of their job and looks forward to further training and understanding the intricacies of trauma registry work.
Takeaways
- 📅 The speaker is about to start a new job and is recording a video to discuss their questions and curiosities about the role.
- 🏥 The new job involves working with ICD-10-CM and ICD-10-PCS codes in a trauma registry setting, which the speaker is about to learn.
- 🤔 The speaker is unsure about the exact process of coding, who is responsible for assigning certain codes, and how information is entered into databases.
- 📚 The speaker is trying to understand the inclusion criteria for trauma cases as defined by the Department of Health Services and how it aligns with hospital and state databases.
- 💻 The speaker's first day involves onboarding, orientation, and familiarizing themselves with the department's procedures and systems.
- 🖥️ The speaker learns about the use of Epic, a healthcare software, and how it interfaces with work queues and patient charts.
- 📈 The speaker is introduced to the Wisconsin America Trauma Society Data Dictionary, which provides detailed information on trauma registry data fields.
- 📆 The speaker discusses the process of reviewing and abstracting data from patient charts to determine if encounters meet inclusion criteria for the trauma registry.
- 🏥 The speaker clarifies that the hospital does not have a separate form for trauma cases; all data is entered into the state registry program.
- 🤝 The speaker will be training with experienced trauma registrars at different hospital sites to gain a comprehensive understanding of the role.
- 😃 The speaker expresses excitement about the new job, the supportive colleagues, and the interesting nature of the work.
Q & A
What is the speaker's new job role and when do they start?
-The speaker's new job role is a Trauma Registrar and they start in approximately one week from the date of the video, which is Friday, February 8th.
What are the ICD-10-CM and ICD-10-PCS codes mentioned in the script?
-ICD-10-CM and ICD-10-PCS are medical coding systems used for diagnosis and procedure coding in healthcare. The speaker is curious about the process of coding and who is responsible for assigning these codes in their new role.
How does the speaker plan to document their learning process in the new job?
-The speaker plans to document their learning process by creating a vlog-style video, sharing snippets of their first days on the job and answering questions they has about the role.
What is the purpose of the trauma registry database?
-The trauma registry database is used to collect and analyze data on trauma patients. It helps hospitals and healthcare systems improve the quality of care for trauma patients by identifying patterns, tracking outcomes, and guiding improvements in trauma care processes.
What is the role of the medical coders in the trauma registry process?
-Medical coders are responsible for assigning diagnosis and procedure codes to patient encounters. Trauma Registrars review these codes to ensure they meet the inclusion criteria for the trauma registry.
How does the speaker plan to verify the accuracy of the trauma codes?
-The speaker will go through the patient charts, looking at the diagnosis codes related to injuries or trauma, and verify if they meet the inclusion criteria. They will also check the work of medical coders to ensure the codes are correct.
What is the inclusion criteria for trauma cases in Wisconsin?
-The inclusion criteria for trauma cases in Wisconsin is outlined in a document on the Department of Health Services website. It specifies what constitutes a trauma case and what information must be present in the medical report for the state to identify and accept it as a trauma case.
How does the speaker's department handle punching in and out for work?
-Instead of using a badge to swipe in and out, the speaker's department uses a phone system to call in. This is a new process for the speaker, who previously worked in medical records where swiping was the standard.
What is the role of the Abbreviated Injury Scale (AIS) in trauma registry work?
-The Abbreviated Injury Scale (AIS) is a trauma coding system used to code and classify the location and severity of injuries. Trauma Registrars use this system to assign codes to injuries based on the documentation in patient charts.
How often does the speaker expect to work from home?
-The speaker expects to work from home in about five or six months. When that happens, they will be provided with two monitors, a keyboard, a mouse, and a docking station to set up a home office.
What is the process for trauma registrars to determine if a patient encounter meets inclusion criteria?
-Trauma registrars run a report of encounters within a specific date range, then review each patient chart to determine if the assigned diagnosis codes meet the inclusion criteria for trauma. They use an Excel spreadsheet to track their progress and make decisions on inclusion or exclusion.
Outlines
📝 Introduction to New Job and Trauma Registry Work
The speaker introduces their upcoming new job, starting a week from the recording date, and expresses curiosity about specific aspects of their role, particularly related to ICD-10-CM and ICD-10-PCS coding. They plan to document their first days on the job and answer questions about the trauma registrar's responsibilities, such as coding and verifying diagnosis and procedure codes, as well as external cause codes. The speaker also discusses their uncertainty regarding the processes of data entry into the hospital and state registry databases, and the criteria for identifying trauma cases.
🏥 First Impressions and Training at the New Job
The speaker shares their initial experiences at the new job, including the onboarding process, the differences in work procedures compared to their previous role, and the technical issues they encountered with their new laptop. They also discuss the Wisconsin America Trauma Society data dictionary, which provides a comprehensive guide for trauma registry work, and their anticipation of upcoming training sessions at different hospital sites.
🔍 Understanding Trauma Registry Process and Coding
The speaker dives deeper into the trauma registry process, explaining how trauma encounters are identified and evaluated for inclusion criteria. They discuss the role of medical coders in assigning diagnosis codes and the trauma registrar's responsibility in reviewing and verifying these codes. The speaker also talks about their excitement in learning the trauma coding system, the Abbreviated Injury Scale (AIS), and their eagerness to apply this knowledge in practice.
📋 Case Findings and Inclusion Criteria Evaluation
The speaker describes the detailed process of reviewing patient encounters to determine if they meet the inclusion criteria for trauma cases. They explain how they use the EHR system to extract data, review patient charts, and assess whether the assigned diagnosis codes align with the reason for hospital admission. The speaker highlights the importance of this phase in their work and expresses enjoyment in this aspect of trauma registry management.
📈 Data Abstraction for State Registry and Assigning AIS Codes
The speaker elaborates on the data abstraction process for the state registry program, detailing how patient demographic information, EMS reports, and clinical data are collected and entered into the registry form. They discuss the trauma registry software's features, such as color coding for required and optional fields, and the automatic calculation of trauma codes. The speaker also explains their unique responsibility to manually assign Abbreviated Injury Scale (AIS) codes based on the patient's injuries, as per the codebook.
🤔 Reflecting on the Trauma Registry Role and Upcoming Training
The speaker reflects on their experiences so far, expressing enthusiasm for the case findings aspect of their role and the grey areas of determining inclusion criteria. They look forward to exploring these areas further and sharing insights in future videos. The speaker also mentions upcoming training at different hospital sites and concludes by expressing their satisfaction with the new job, feeling that it is a perfect fit for them.
Mindmap
Keywords
💡Trauma Registry
💡ICD-10-CM and ICD-10-PCS
💡Coding
💡Inclusion Criteria
💡EHR (Electronic Health Record)
💡Medical Coders
💡Trauma Registrars
💡Abbreviated Injury Scale (AIS)
💡State Registry Database
💡Work Queue
Highlights
The speaker is about to start a new job and is curious about various aspects of trauma registry work.
The speaker discusses the process of coding ICD-10-CM and ICD-10-PCS and who is responsible for this task.
The role of trauma registrars in verifying the accuracy of medical coding is mentioned.
The speaker is unsure about the system used for entering trauma-related information into the hospital's registry database.
There are questions regarding the state registry database and its relationship with the hospital's database.
The speaker is interested in the inclusion criteria for trauma cases as set by the Department of Health Services.
The speaker's first day of work involves onboarding and orientation, including learning about punching in and out with a phone call.
The speaker receives a new laptop but it lacks the correct program for email and calendar access.
The Wisconsin America Trauma Society data dictionary is mentioned as a valuable resource for trauma registrars.
The speaker is excited to learn the trauma coding system using the Abbreviated Injury Scale (AIS).
The process of identifying trauma encounters and determining if they meet inclusion criteria is described.
The speaker explains how trauma registrars use an Excel spreadsheet to track and manage cases.
The role of medical coders in assigning diagnosis and procedure codes is clarified.
The state registry program is used to abstract data from patient charts and submit it to the state or national database.
The speaker's responsibility to assign the Abbreviated Injury Scale (AIS) codes is highlighted.
The speaker finds the case-finding section of the job, which involves reviewing patient charts for inclusion criteria, to be the most interesting.
The speaker expresses excitement about the job and the learning process, finding it engaging and enjoyable.
The speaker plans to share more insights and experiences as they continue to learn and develop new skills in their new role.
Transcripts
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