Carolina Lucero, RN, CAPA
Sutter Memorial Medical Center
Turlock,CA
1
Certification
32
years of professional experience
I am a highly analytical and detail-oriented Registered Nurse with 26+ years of comprehensive clinical experience, specializing in comprehensive short reviews, pre-admission testing, and critical patient assessments. Proven expertise utilizing Epic Systems to evaluate complex medical histories, history and physical(H&P) records, cardiac clearances, diagnostic labs, and medication reconciliation to ensure patient safety and regulatory compliance. Exceptional cross-functional coordination skills across high-velocity departments. Seeking to leverage advanced clinical review, auditing, and assessment skills in a dedicated Chart Review, Clinical Documentation Integrity position.
Work History
Pre-Admit Testing Department RN & Charge RN
14 Years- Utilize Epic Systems to evaluate and combine full patient records, H&Ps, cardiac clearances, laboratory diagnostics, and EKGs to validate compliance for operating room admissions
- Conduct 8 to 10 clinical interviews daily with preoperative surgical patients to construct precise medical histories, assess surgical readiness, and collaborate with Primary and Specialty physicians to facilitate the surgical process.
- Medication reconciliation protocols, identifying potential high-risk contraindications to optimize surgical patient safety.
- Serve as Charge Nurse, orchestrating daily operations, managing staffing resources, coordination workflows for a department averaging 12 Registered Nurses across PAT and surgical service lines, collaborating with Same Day Surgery and Operating Room Charge Nurse for next day patient readiness.
- As a Float Surgical Service RN, I demonstrated my clinical expertise by floating seamlessly across the high intensity environments of Post-Anesthesia Care Unit (PACU), Same Day Surgery (SDS), GI, and Pain Management to support staffing deficits and maintain continuity of care.
Urgent Care Registered Nurse
1 Year 4 Months- Executed rapid, high-accuracy triage and clinical assessments for diverse patient populations ranging from infants to geriatrics utilizing EPIC EHR.
- Managed acute treatments for complex clinical presentations, including cardiac events, stroke protocols, respiratory distress, and advanced wound care.
- Administered complex intravenous infusions and assisted physicians with minor surgical and diagnostic procedures in a fast-paced clinical setting.
Registered Nurse
17 Years 3 Months- Critical Recovery evaluation and stabilization of post-intervention patients (OR, GI, Cath Lab, emergency L&D C-section), ensuring all post-operative documentation precisely reflected the actual intensity of nursing and medical resources used.
- Multi-Departmental Charting, matinee detailed documentation across high acuity environments including the Emergency Department, PACU and SDS-Pre/Post Op, focusing on complete clinical clarity during safe rapid transitions of care.
- Revenue Cycle Base; 6 years as an ER Admitting Clerk prior to nursing career, establishing a deep foundational understanding of medical demographics, patient tracking, and healthcare registration compliance.
Staff RN - MedicalTelemetry Unit
1 Year 3 Months- Complex Record Management: Managed care of and extensive electronic documentation for multi-system, high-acuity patients, including renal, cardiac, and ventilator-dependent cases.
- Collaborated with interdisciplinary teams to develop comprehensive care plans for patients.
- Educated patients and families on treatment plans, promoting adherence to medical advice.
- Monitored patient conditions, documenting vital signs and changes in health status.
- Administered medications and treatments according to established protocols and physician orders.
Education
Associate of Science - Nursing
Skills
Clinical Documentation Review & Auditing
Epic Systems EHR Proficiency
Pre-Admission Testing (PAT) Optimization
Comprehensive Risk Assessment
Severity of Illness
Interdisciplinary Collaboration
Concurrent and Retrospective Review
Affiliations
American Society of PeriAnesthesia Nurses
Certification
- Registered Nurse (RN) License | State of California
- Certified Ambulatory Perianesthesia Nurse (CAPA)
- Basic Life Support (BLS); Trauma Care After Resuscitation (TCAR)
Timeline
Pre-Admit Testing Department RN & Charge RN
Sutter Memorial Medical Center
08.2012 - CurrentRead More
Urgent Care Registered Nurse
Sutter Gould Medical Foundation
08.2011 - 12.2012Read More
Staff RN - MedicalTelemetry Unit
Doctors Medical Center
06.2000 - 09.2001Read More
Registered Nurse
Emanuel Medical Center
05.1994 - 08.2011Read More
Merced Community College
Associate of Science from Nursing
Read More