Job Description

Clinical Data Abstractor

The Clinical Data Abstractor reviews medical records and abstracts key data elements into the quality measure and clinical registry databases. Data accuracy and timeliness maintained to support ongoing needs of internal quality review and process improvement as well for reporting to outside agencies. Supports the importance of accurate, complete, timely and consistent documentation practices for the production of quality healthcare data. This position is fully integrated into the organizational framework and has the authority and resources to fulfill all the duties outlined above, including timely data entry to the Registry with full and unrestricted access to medical records.

Job Duties

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson
• Abstract, interpret and classify clinical information in the medical record according to the Specifications Manual for National Hospital Inpatient and Outpatient Quality measures as it relates to quality abstraction data collection to benchmark against other hospitals and for submission to accrediting agencies
• Review and abstract records for certain patient populations for compliance with The Joint Commission ORYX and Quality Measures criteria.
• Clearly and accurately record all findings in MBASQIP, NSQIP, Get with Guidelines (GWTG) and Medisolv abstract forms and/or direct data enter findings into the Registry databases and tracking forms. Create reports for Quality Department to evaluate clinical practice trends.
• Participate in Quality Abstraction inservice meetings or training sessions to maintain and enhance abstraction skills, to stay abreast of changes in abstraction guidelines/regulations. Attend interdisciplinary meetings to review quality measure data outcomes and process. Enter daily productivity into the Clinical Data Abstraction Productivity log. Consistently meet or exceed departmental minimum accuracy and productivity rates.

Minimum Qualifications

• Extensive knowledge of medical terminology, human anatomy and physiology, and clinical disease process required.

Preferred Qualifications

• Associate's Degree or BS in Health Information Management, Nursing or related field
• Previous work experience in medical record abstraction activities preferred.
• Knowledge of Medisolv and Get with the guidelines abstraction systems preferred.
• Familiarity with computers and Microsoft Office applications preferred.

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