By Michael Trelow, CSTR, CAISS
Data validation serves as a critical educational tool for Trauma Registry Professionals, enhancing their skills, improving data quality for trauma centers, and ultimately contributing to better patient care. The process of validation highlights areas of weakness and encourages registrars to seek further training, ensuring that data entry remains accurate.
Various methods of data validation exist for the trauma registry, allowing trauma centers to select tools that best fit their needs. The primary goal is to ensure Trauma Registry Professionals extract the most accurate data from the electronic health record (EHR) and transfer it to the registry.
The Guidelines
The National Trauma Data Standard (NTDS) serves as the essential data dictionary for all trauma registrars. It details all required data fields, providing definitions, element values, and additional information to ensure correct data entry. The NTDS includes a data source hierarchy guide, directing registrars to the appropriate documents for data retrieval. It also outlines associated edit checks, specifying that Level 1 and 2 edit checks must be corrected before data can be uploaded to the National Trauma Data Bank (NTDB).
Some states use statewide trauma data dictionaries that adhere to the NTDS format while tracking additional data fields. Hospital-based data dictionaries are designed to indicate where to obtain data from the electronic health record (HER). They should include an additional column specifying the exact location in the EHR to pull the data. This will assist new registrars in accurately entering data into the trauma registry.
According to the American College of Surgeons (ACS), up to 10% of the total charts per month must be validated. There are two schools in data validation of the trauma registry:
Continues Improvement through Validation
In data validation, you aim to identify patterns of missed or incorrect data. If a pattern is detected, you can guide the registrar to relevant courses to improve their understanding. Options include trauma registrar courses, International Classification of Diseases Courses (ICD-10), and Abbreviated Injury Scale Courses (AIS). Sharing validation scores on a shared drive allows the Trauma Program Manager and Trauma Medical Director to quickly review the inter-rater reliability (IRR) of the trauma registrars, ensuring high-quality reports from the registry.
In conclusion, there are many ways to validate a record for the Trauma Registry Professional. The main point is to be educational because no one is perfect. It should be a two-way street where the reviewer identifies the missing/incorrect data, presents it to the registrar and the registrar can show the reviewer where they got the data. All of this is done to help the registrar abstract and enter high-quality data to help the hospitals improve the treatment of the injured patient.
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