Experienced Registered Nurse with over 10 years in clinical documentation review and patient outcome evaluation. Expertise in auditing chart compliance and converting complex patient histories into precise quality data. Collaborates with multidisciplinary teams to enhance quality improvement and uphold regulatory compliance while maintaining strict HIPAA standards.
Work History
Admissions Registered Nurse
6 Years 1 Month
Kindred At Home Home Health | 08.2016 - 09.2022
Perform comprehensive medical record reviews and data extraction to ensure clinical documentation meets home health regulatory requirements and patient-centered care goals.
Audit admission, recertification, and discharge documentation, identifying data gaps and updating care plans based on ongoing assessments.
Abstract patient data to prepare detailed medical documentation, including medication order changes, progress updates, and case conferences.
Ensure strict adherence to HIPAA guidelines and data integrity across electronic health records while managing care coordination.
Supervise personal care plans and audit documentation submitted by Home Health Aides to ensure compliance with physician orders.
Assessed patient needs and developed individualized care plans to ensure optimal health outcomes.
Educated patients and families on treatment protocols, medication management, and post-discharge care instructions.
School Nurse / Health Data Liaison
3 Years 11 Months
Asheboro City Schools | 08.2012 - 07.2016
Managed and analyzed health records and care plans for 500+ students and staff, facilitating coordinated care and informed decision-making.
Evaluated acute and chronic condition data to track treatment progress, enabling timely referrals and improved patient outcomes.
Served as clinical liaison between families, administration, and external healthcare providers, ensuring accurate health data exchange and continuity of care.
Registered Nurse
1 Year 2 Months
Randolph Hospital | 06.2011 - 08.2012
Reviewed and documented clinical findings for patients with complex cardiopulmonary, medical, and surgical conditions, ensuring comprehensive patient care.
Maintained accurate clinical charts and documentation for wound care and pain management, supporting effective surgical recovery pathways.
Administered medications and treatments per physician orders, ensuring patient safety and adherence to protocols.
Monitored patient vital signs, documenting changes and communicating critical information to healthcare team promptly.
Developed and implemented individualized care plans based on patient assessments and ongoing evaluations.
Education
Bachelor of Science - Nursing
Winston-Salem State University | Winston-Salem, NC