Charlotte Marks
Culbertson,NE
Summary
Dynamic Transition of Care Nurse with expertise in patient education and care coordination at Community Hospital. Proven ability to enhance chronic disease management through interdisciplinary collaboration and effective communication. Skilled in electronic medical records and committed to regulatory compliance, ensuring optimal patient outcomes and satisfaction. Recognized for providing emotional support to patients and families during critical times.
Overview
2026
2026
years of professional experience
1
1
Certification
Work History
Transition of Care Nurse/Patient Educator
Community Hospital
McCook, Nebraska
08.2021 - Current
- Communicated effectively with patients and families regarding care procedures.
- Collaborated with healthcare team to provide quality patient support.
- Educated patients on medication management and health maintenance practices.
- Engaged in continuous learning to enhance nursing skills and knowledge base.
- Maintained accurate records of patient visits and treatments in electronic medical record system.
- Advised the family members regarding taking care of the elderly or disabled at home.
- Coordinated with other healthcare professionals for smooth patient flow throughout hospital units.
- Developed comprehensive patient care plans based on assessment results and physician orders.
- Counseled and educated patients and caregivers on diagnoses, chronic disease self-management, wound management and medications.
- Collaborated with interdisciplinary team members to develop treatment plans that optimize patient outcomes.
- Participated in continuing education programs to stay abreast of latest trends in nursing practice.
- Conducted client assessments in order to identify individual needs.
- Provided emotional comfort to the patients suffering from terminal illness.
- Counseled family members on how to cope with stress caused by serious illnesses.
- Educated patients and families about health maintenance, disease prevention and treatments.
- Reported patient assessment findings and physical and psychosocial responses to nursing intervention for progress towards care goals.
- Coordinated with healthcare team to establish, enact, and evaluate patient care plans.
- Collaborated with health groups to plan or implement programs designed to improve overall health of communities.
- Referred patients to specialized health resources or community agencies to furnish additional assistance.
- Educated patients on treatment plans and medication management.
- Coordinated discharge planning to ensure continuity of care post-hospitalization.
- Assisted in developing educational materials for patient programs.
- Collaborated with healthcare teams to address patient concerns effectively.
- Provided one-on-one support to patients during their healthcare journey.
- Worked with medical professionals to provide complex clinical care management, patient education, and counseling.
- Provided patient education on diagnoses, treatments, and discharge plans.
- Met with patients and family members to explain procedures, respond to questions, and educate on proposed actions to improve health.
- Assisted in the development of educational programs for individuals with chronic illnesses or disabilities.
- Assessed patient knowledge level prior to providing instruction in order to customize teaching sessions accordingly.
- Promoted awareness among patients of available resources in their communities that can assist them in managing their conditions.
- Coordinated with healthcare team members to ensure optimal care delivery and patient satisfaction.
- Educated patients regarding medication use including side effects, interactions and adherence strategies.
- Maintained accurate records documenting all patient encounters including assessment data, interventions used, follow up activities performed.
- Developed educational materials for patients to promote self-management of chronic diseases.
- Conducted and coordinated health needs assessments and other public health surveys.
- Screened clients for variety of health risk factors to make appropriate referrals.
- Boosted community members' health knowledge through participation in health fairs and events.
- Presented health education talks at training workshops and conferences in local area.
MDS Coordinator
Hillcrest Nursing Home
McCook, Nebraska
2013 - 08.2021
- Conducted comprehensive assessments to determine resident care needs and preferences.
- Coordinated interdisciplinary team meetings to ensure effective communication among staff.
- Developed individualized care plans based on resident evaluations and family input.
- Managed documentation for compliance with regulatory standards and quality measures.
- Educated staff on MDS processes and state regulations to enhance understanding.
- Reviewed resident records regularly to maintain accuracy and completeness of data.
- Collaborated with healthcare professionals to optimize patient care strategies and interventions.
- Facilitated team meetings with members from other departments such as Social Services, Dietary, Activities, Rehabilitation services, to discuss resident issues and concerns related to the MDS process.
- Developed individualized plans of care for each resident based on assessment findings.
- Collaborated with interdisciplinary teams to develop comprehensive care plans.
- Monitored residents' progress and updated MDS records accordingly.
- Coordinated timely submission of all required documents including Minimum Data Set forms, Care Area Assessments, Quarterly Assessment Reconciliation, Annual Assessment Reconciliations and other regulatory paperwork.
- Conducted assessments to determine the resident's functional and cognitive abilities, as well as their level of care needs.
- Performed data entry functions associated with entering information into computer systems used for tracking and monitoring purposes.
- Participated in survey preparation activities by ensuring that all necessary documents were available during surveys conducted by state agencies or accreditation organizations.
- Ensured that changes made to an existing plan of care corresponded with appropriate changes made on the corresponding MDS form.
- Assisted in identifying opportunities for improvement in processes related to the completion of the MDS form.
- Audited monthly MDS submissions for accuracy, timeliness, completeness and compliance with applicable regulations.
- Researched new developments in Medicare and Medicaid reimbursement policies related to long-term care facilities.
- Verified quality of assessments in accurately reflecting physical, mental and psychosocial status of each resident.
- Compiled reports from various systems regarding utilization review outcomes and quality indicators as requested by management staff.
- Prepared annual reviews of all residents' medical records according to federal guidelines.
- Trained and supervised health care workers conducting resident assessments.
- Interpreted physician orders for accuracy and completeness prior to submitting them electronically into the MDS system.
- Increased productivity and efficiency by regularly reevaluating processes and technologies.
Education
BSN - Nursing
Capella University
Online01-2022
RN - Nursing
Missouri State University
West Plains, MO12-2006
Skills
- Patient education
- Care coordination
- Interdisciplinary collaboration
- Electronic medical records
- Regulatory compliance
- Health assessment
- Chronic disease management
- Community health outreach
- Team leadership
- Emotional support
- Preventative care
- Treatment coordination
- Patient needs assessment
- Clinical documentation
Accomplishments
- I was nominated and received the Caring Kind award though the NHA.
- I was asked to and attended the Leadership Institute though the NHA.
Affiliations
- I am a volunteer for the Culbertson Rescue.
Certification
- I am a CPR instructor though AHA.
Timeline
Transition of Care Nurse/Patient Educator
Community Hospital
08.2021 - Current
MDS Coordinator
Hillcrest Nursing Home
2013 - 08.2021
BSN - Nursing
Capella University
RN - Nursing
Missouri State University
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