Dedicated Clinical Documentation Specialist with a background as a Clinical Coordinator for Orthopedics looking for opportunities to utilize experience in achieving organizational goals and objectives by performing quality record reviews, submitting impactful queries, and collaborating with an effective team.
Perform reviews on clinical documentation and issue queries when appropriate to clarify missing, unclear, or conflicting documentation
Accurate and timely review of records to include an initial, subsequent, and retrospective reviews
Review records to identify the most appropriate principal and secondary diagnosis to accurately reflect the patient's severity of illness and risk of mortality
Perform review on clinical documentation and issue queries when appropriate to clarify missing, unclear, or conflicting documentation
Accurate and timely review of records to include new, concurrent and retrospective reviews
Review records to identify most appropriate principal and secondary diagnosis to accurately reflect the patient's severity of illness and risk of mortality
Works closely with coders to ensure appropriate DRG, SOI and ROM
Collaborates with Infection Prevention and Quality to identify HAC and PSI
Assist with staff and provider education when needed
Expedited accurate clinical documentation completion by promptly responding to queries from healthcare providers and support staff, offering timely guidance and support.
Assist pts with the post care of having knee, hip, shoulder, and spinal surgeries
Assist pts with transferring from bed to chair, post-operative ambulation, and pain management
Proficient in removing drains from incision sites and re-dressing incisions, monitoring pt vital signs and consciousness to determine over sedation of pt
Performing a complete head to toe assessment of pts and assisting physicians with any bedside procedure that the pt may require
2015 till present Clinical Coordinator position, pre-op education to all elective total joint replacement patients, delegating tasks to staff, chart reviews and audits, core measure compliance with pre-op antibiotics and foley catheter insertion, care, and discontinuation, audit of patients chart to monitor neuro assessments as well as care plans are patient specific, and pt education is performed, monthly staff schedule and daily staffing of unit, time keeping and adjustments in payroll, approval of payroll, established admission and discharge checklist, perform competencies of staff in care plans, established individual staff education binders, performs daily joint commission readiness check list, active participant in accreditation with Joint Commission to include preparing unit and staff for survey, precepts all new staff members to unit, provide education to all staff members in pain management, monthly handwashing monitoring and compliance, monitor all orthopedic physician orders and address any issues, needs or concerns, along with assisting case managers in identifying equipment needs as well as home health versus skilled nursing facility needs, and weekly inventory of department and ordering of needed supplies
As a member of this program I was required to rotate throughout the facility utilizing my nursing skills
I worked on the Cardiac Unit, Joint and Spine Unit, Nursery, Oncology unit, and Post-Surgical Unit
I remained efficient in my nursing skills such as starting IV's, inserting foley catheters, using a bladder scanner, working with the Patient Touch medication scanning system, and computer charting.
Assist physicians during outpatient procedures including: colonoscopy, upper endoscopy, bronchoscopy, EUS with fine needle aspirations, ERCP with stent placements, liver biopsy and paracentesis and feeding tube placements
Proficient in conscious sedation, monitoring patient vital signs during procedures, labeling of specimens, completes admission process including admission assessment, nurse notes, MD orders and medication reconciliation forms
Trained in drawing blood for lab work, recovery and discharge of patients, interaction with family members including post-op education, maintaining advanced learning criteria for staff members, charge nurse on rotating days, precepting new employees, daily assignments, and logging patients into computer system
Experience in admitting patients to the unit, assessment and monitoring of patients, administering medications, starting IV therapy, inserting foley catheters and Naso Gastric tubes, assisting physicians at the bedside for chest tube insertions and thoracentesis, charge nurse of the unit during evening and weekend shifts, and providing support and chart review for
LPN's.