Organized and knowledgeable Registered Nurse experienced in treating and caring for patients. Successful in providing fast and accurate assessments and working calmly under pressure. Recognized for collaborating well with doctors to maintain top-notch healthcare practices.
Overview
6
6
years of professional experience
Work History
Registered Nurse
San Pablo Healthcare & Wellness Center
Pablo, CA
11.2023 - Current
Developed educational materials for use in teaching sessions with patients or their families.
Coordinated discharge planning activities including arranging follow up appointments or referrals for additional services.
Documented patient progress notes accurately and efficiently in the electronic medical record system.
Participated in multidisciplinary team meetings to discuss patient care plans.
Monitored vital signs, administered injections, and provided assistance with medical procedures.
Performed triage assessments of walk-in patients in a clinic setting.
Ensured compliance with standards of professional practice as well as state and federal regulations related to health care delivery services.
Ensured compliance with regulatory agencies such as The Joint Commission and Centers for Medicare and Medicaid Services.
Demonstrated knowledge of current trends in nursing practices by attending continuing education classes or seminars.
Instructed patients on proper self-care techniques at home following discharge from the hospital.
Actively participated in quality improvement initiatives within the department.
Provided patient care and education to patients with chronic illnesses.
Evaluated effectiveness of interventions through ongoing assessment of patient responses.
Assessed, planned, implemented and evaluated nursing care for assigned patients.
Utilized critical thinking skills to assess clinical situations quickly and accurately.
Collaborated with physicians, nurses, therapists, social workers and other healthcare professionals to develop individualized treatment plans for each patient.
Maintained a safe environment for all patients by adhering to infection control policies and procedures.
Demonstrated ability to work independently as well as collaboratively within a team environment.
Provided emotional support and comfort to families during difficult times.
Created, implemented and evaluated patient care plans with medical team.
Administered medications and treatments, monitoring patients for reactions and side effects.
Adhered to infection control procedures to facilitate safe, clean patient environment.
Acted as patient advocate and implemented total patient care through team nursing process.
Conducted intake assessments with patients and relatives to gather case history.
Provided patient and family health education focusing on self-management, prevention and wellness.
Recorded patient condition, vital signs, recovery progress and medication side effects.
Administered medications, tracked dosages, and documented patient conditions.
Monitored and managed various treatment and care interventions.
Collected lab specimens, ordering and interpreting diagnostic tests and lab results.
Maintained personal and team compliance with medication administration standards and patient care best practices.
Updated charts throughout shifts with current, accurate information to maintain strict recordkeeping standards.
Maintained thorough, accurate and confidential documentation in electronic medical records.
Monitored diet, physical activity, behaviors and other patient factors to assess conditions and adjust treatment plans.
Observed strict safety measures, including checking medication dosages before administration to patients.
Conducted specified laboratory tests to help detect conditions and determine diagnosis.
Administered oral, IV and intra-muscular medications and monitored patient reactions.
Admissions Coordinator
San Pablo Healthcare & Wellness Center
San Pablo, CA
05.2021 - Current
Referring patients to other programs or organizations, if necessary.
Preparing admissions reports by collecting, analyzing, and summarizing data and trends.
Managing the onboarding patients
Organizing patient records and documentation.
Checking patients into the system as they arrive.
Updating electronic health records and processing documentation.
Maintaining communication with insurance companies.
Developing business relationships with physicians and marketing home health
Providing operational shift oversight and facilitating timely patient admission, transfer, and discharge.
Social Services Assistant
Baywood Court Skilled Nursing
Castro Valley, CA
04.2020 - 10.2022
Provided guidance and referrals for clients seeking additional resources outside of the organization's scope.
Developed partnerships with local organizations that offer assistance to individuals in need.
Provided support to clients in developing independent living skills, such as budgeting and time management.
Developed plans of care based on assessments of clients' needs and resources available.
Assessed eligibility requirements for various public assistance programs and verified application documents.
Coordinated transportation arrangements for clients needing access to medical appointments or job interviews.
Served as a liaison between clients, families, external agencies, and other stakeholders.
Assisted clients with completing applications for government services and benefits.
Participated in team meetings with other social service professionals to discuss best practices.
Organized groups and individual meetings to discuss issues related to social service programs.
Formulated discharge plans in collaboration with multidisciplinary treatment team, patient and family.
Promoted integration of behavioral health care and long-term services to enhance continuity of care for clients.
Conducted psychosocial assessments to identify individual needs and specific social services necessary to address identified objectives and goals.
Presented clients with information, referrals and assistance accessing resources such as food, housing and transportation.
Made referrals to utilize community resources for resident's needs.
Prepared patients for self-management and decision-making responsibilities.
Guided clients through transition to independent living within community.
Medical Records Director
Legacy Healthcare Services
Martinez
04.2018 - 03.2021
Reviewed medical records for accuracy, completeness and compliance with applicable laws and regulations.
Assisted in the development of coding guidelines for clinical services provided by healthcare providers.
Coordinated activities between departments relating to completion, retention, release of patient's medical records.
Oversaw daily operations ensuring compliance with established departmental policies, procedures, standards.
Ensured timely release of information in accordance with federal and state laws, accreditation standards, organizational policy and other regulatory requirements.
Participated in committees that addressed quality assurance initiatives related to medical records management.
Provided guidance regarding legal implications associated with release of information contained in a patient's chart.
Developed workflow processes that ensured efficient utilization of resources while maintaining high quality standards.
Maintained accurate inventory control systems for all paper-based medical records.
Analyzed data from various sources including physician orders, laboratory results, radiology reports, to ensure complete documentation within patient's chart.
Trained staff on proper use of the electronic health record system.
Resolved complex issues related to medical record retrieval requests from external sources such as attorneys, insurance companies or government agencies.
Conducted audits of medical records to identify areas needing improvement or corrective action.
Evaluated patient care documentation to ensure accuracy of data entry into electronic health record system.
Developed and implemented policies and procedures to ensure compliance with HIPAA regulations.
Developed, implemented and maintained medical records policies and procedures.
Established and upheld procedures for medical records collection, coding and filing.
Managed well-organized system of closed and open medical records with ready availability to interdisciplinary personnel.
Maintained record of authorized information taken from charts.
Education
Bachelor of Science - Nursing
Colegio De San Agustin
Bacolod Philippines
03-1995
Skills
Chart updating
ADL Assistance
Appointment Scheduling
Medical Recordkeeping
Care Planning
Infectious disease control
Wound Care
Mobility Assistance
Patient Care
Patient Monitoring
Languages
Tagalog
Professional
English
Professional
Timeline
Registered Nurse
San Pablo Healthcare & Wellness Center
11.2023 - Current
Admissions Coordinator
San Pablo Healthcare & Wellness Center
05.2021 - Current
Social Services Assistant
Baywood Court Skilled Nursing
04.2020 - 10.2022
Medical Records Director
Legacy Healthcare Services
04.2018 - 03.2021
Bachelor of Science - Nursing
Colegio De San Agustin
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