Reporting to the Director Clinical Quality Registries and Outcomes for MedStar Heart and Vascular Institute (MHVI) the Clinical Data Specialist is responsible for data collection data management accuracy and integrity of hospital outcomes data. Supports MHVI system level quality & registry initiatives.
Primary Duties and Responsibilities
Abstracts administrative and clinical data from patient records in accordance with regulatory and database abstraction guidelines. Provides required information in a format that is compliant with internal quality standards and those of the registries and / or databases.
Maintains current knowledge of abstraction rules and ensures data accuracy. Collects synthesizes and enters appropriate clinical data into designated repository (paper and/or computer format) to support database repository. Completes data entry in a timely way.
Participates in data validation and reporting. Interfaces with members of the medical and surgical teams and others as required obtaining required data and ensuring documentation is accurate complete timely and compliant with medical record and regulatory / database requirements.
Screens medical record charts for specific complications related to mortality and morbidity within MHVI.
Assists in the data abstraction for specific projects related to quality control.
Assists in the design of data collection strategies.
Maintains current clinical expertise in assigned populations.
Identifies trends and opportunities for improvement in clinical performance.
Prepares and presents data to administrative and clinical groups to facilitate performance improvement and implementation of evidence based practice. Generates weekly QA and ad hoc reports as assigned. Reviews reports for accuracy and reliability.
Participates in performance improvement initiatives as the expert in data abstraction and documentation guidelines. Participates in quality and performance improvement efforts as required.
Develops/maintains familiarity with hardware and software and reporting tools
Maintains routine trouble shooting skills with standard computer applications and database software. Works with vendor technical staff as needed.
Supports and upholds institutional policy on release of data patient confidentiality and database security standards. Ensures integrity of database through maintaining compliance with established standards on a daily basis.
Maintains effective communication channels between administrative clinical and professional staff.
Attends clinical quality and data meetings appropriate to area of clinical expertise.
Supports regional MHVI efforts as assigned.
Participates in Regulatory Readiness and Patient Safety activities as assigned.
Minimal Qualifications
Education
Bachelor's degree in nursing clinical research or another relevant field required
Experience
3-4 years of progressively more responsible job related experience required
1-2 years Experience in abstracting information from charts in an efficient manner and proven writing skills required
Licenses and Certifications
Completion of Institute for Healthcare Improvement (IHI) Open School within 1 Year required
RN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia for holders of Bachelor's degree in Nursing preferred
Knowledge Skills and Abilities
Familiarity with general data standards database management and computer technology.