Erica Moreau
Poland
Summary
Experienced Clinical Documentation Specialist with background in healthcare settings. Demonstrated mastery of medical terminology, coding fundamentals, and compliance requirements. Strengths include critical thinking, process improvement strategies and strong interpersonal communication skills. Previous roles involved enhancing clinical documentation processes for accuracy, leading to improved quality of patient care and streamlined operations.
Overview
17
17
years of professional experience
Work History
Clinical Documentation Specialist
Central Maine Health Care
Lewiston
02.2021 - Current
- Reviewed diagnostic and procedural terminology for consistency with acceptable medical nomenclature.
- Collaborated with interdisciplinary teams to identify opportunities for improvement in clinical documentation processes.
- Reviewed medical records to ensure accuracy and completeness of clinical documentation.
- Worked with speed, efficiency and accuracy to process documentation and complete projects.
- Worked effectively in team environments to make the workplace more productive.
- Managed time effectively to ensure tasks were completed on schedule and deadlines were met.
- Acquired strong background in medical terms, illnesses and conditions and medical procedures.
- Participated in regular meetings with physicians, nurses, case managers, coders, therapists. to discuss changes or improvements needed for clinical documentation processes.
- Created educational materials related to best practices for accurate clinical documentation across all settings.
Registered Nurse
Central Maine Medical Family
Lewiston
07.2013 - Current
- Trained and mentored new RNs on best practices, hospital policies and standards of care.
- Participated in multidisciplinary team meetings to discuss patient care plans.
- Advocated for patients by supporting and respecting basic rights, values, and beliefs.
- Oversaw patient admission and discharge processes to coordinate related paperwork.
- Updated charts throughout shifts with current, accurate information to maintain strict recordkeeping standards.
- Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.
- Counseled patients regarding medication side effects or lifestyle changes necessary for improved health outcomes.
- Coordinated with healthcare team to establish, enact and evaluate patient care plans.
- Monitored vital signs, administered injections, and provided assistance with medical procedures.
- Administered local, inhalation or intravenous anesthetics to patients undergoing procedures.
Registered Nurse, Cardiac Unit
MaineGeneral Health
Augusta
06.2010 - 06.2013
- Performed laboratory testing such as blood draws or EKGs.
- Ensured compliance with all relevant regulations governing the practice of nursing.
- Monitored diet, physical activity, behaviors and other patient factors to assess conditions and adjust treatment plans.
- Administered oral, IV and intra-muscular medications and monitored patient reactions.
- Responded quickly and appropriately to life threatening situations within the unit.
- Assessed, monitored and evaluated patient vital signs.
- Documented patient progress notes according to established standards of care.
- Performed ECG tests and interpreted results for diagnosis purposes.
CNA
MaineGeneral Health
Augusta
06.2008 - 06.2010
- Monitored vital signs such as pulse rate, respiration rate, and blood pressure.
- Assisted with range of motion exercises and other rehabilitative activities per physician orders.
- Collected specimens, monitored vitals and maximized patient comfort to maintain optimal environment.
- Measured and recorded food and liquid intake and output, reporting changes to medical or nursing staff.
- Reported changes in patient conditions to registered nurse or physician.
Education
Associate of Science - Nursing
University of Maine
Augusta, ME06-2010
Skills
- Patient assessment
- Medication administration
- Vital signs monitoring
- Laboratory testing
- ECG interpretation
- Regulatory compliance
- Team collaboration
- Time management
- Effective communication
Timeline
Clinical Documentation Specialist
Central Maine Health Care
02.2021 - Current
Registered Nurse
Central Maine Medical Family
07.2013 - Current
Registered Nurse, Cardiac Unit
MaineGeneral Health
06.2010 - 06.2013
CNA
MaineGeneral Health
06.2008 - 06.2010
Associate of Science - Nursing
University of Maine
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