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Clinical Quality Data Registrar
Company | Yuma Regional Medical Center |
Address | Yuma, AZ, United States |
Employment type | FULL_TIME |
Salary | |
Category | Hospitals and Health Care |
Expires | 2023-09-08 |
Posted at | 9 months ago |
Summary
- 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.
- 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.
- Enters abstraction information into the appropriate databases to permit data aggregation and statistical analysis.
- 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.
- Other duties as assigned.
- 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.
- 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.
- Conducts interviews with patients to verify quality and safety processes; interviews and observes staff practices to measure compliance with established quality and safety processes.
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