Brenda Long
Morganton,NC
Summary
Dedicated Clinical Documentation Specialist with strong skills in regulatory compliance and patient assessment. Proven ability to enhance documentation accuracy and educate staff on best practices.
Overview
35
35
years of professional experience
Work History
RN, BSN Clinical Documentation Specialist
Frye Regional Medical Center
Hickory, North Carolina
03.1991 - 04.2026
- Reviewed clinical documentation for accuracy and compliance with regulatory standards.
- Collaborated with healthcare providers to enhance accuracy and compliance in clinical documentation.
- Educated staff on clinical documentation and coding best practices to ensure regulatory adherence.
- Analyzed medical records to identify documentation gaps and recommended actionable improvements.
- Monitored changes in healthcare regulations affecting clinical documentation requirements.
- Facilitated interdisciplinary meetings to address documentation challenges and streamline processes.
- Monitored compliance with regulatory standards for the Clinical Documentation Improvement program.
- Monitored vital signs of patients during medical procedures to ensure their stability. and administered injections during medical procedures.
- Trained and mentored new RNs on best practices and hospital policies.
- Administered medications while monitoring patients for reactions and side effects.
- Collaborated with multidisciplinary teams to develop patient care plans.
- Educated patients and families on health management and post-discharge care.
- Assisted in emergency procedures, providing critical support during crises.
- Utilized critical thinking skills to assess clinical situations quickly and accurately.
- Coordinated discharge planning activities including arranging follow up appointments or referrals for additional services.
- Conducted intake assessments with patients and relatives to gather case history.
Education
Bachelor of Science - Associate in Nursing
Western Piedmont Community College
Morganton, NC05-1983
Bachelor of Science - Nursing
Winston Salem State University
Winston-Salem, NC01-1996
Skills
- Clinical documentation review
- Regulatory compliance
- Clinical coding
- Documentation auditing
- Quality assurance
- Patient assessment
- Care planning
- Interdisciplinary collaboration
- Process optimization
Timeline
RN, BSN Clinical Documentation Specialist
Frye Regional Medical Center
03.1991 - 04.2026
Bachelor of Science - Associate in Nursing
Western Piedmont Community College
Bachelor of Science - Nursing
Winston Salem State University