Ginger Copeland
Registered Nurse
Amarillo,TX
Work Preference
Summary
Clinical documentation expert with strong analytical and organizational skills. Effective team collaborator focused on achieving results and adapting to changing needs. Skilled in medical terminology, coding, and compliance, ensuring accurate and thorough documentation. Reliable communicator with commitment to quality and precision.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Remote Senior Clinical Documentation Specialist (QARN)
Good Samaritan Society Home Health
Amarillo, TX
03.2020 - Current
- Responsible RN with excellent communication skills demonstrated by 21 years of experience in healthcare. Specialized in intensive cardiac care for 14 years and community nursing for 7 years.
- Strong clinical judgment and independent clinical decision making
- Preceptor/Educator training new staff.
- High level of autonomy and responsibility with a remote position.
- Strong understanding of OASIS, Coding, and plan of care reviews.
- Patient advocate
- Chart audits and evaluation
- Adept at prioritizing/managing deadlines
- Knowledge of Epic, Meditech, ICD 10 coding, and Netsmart applications
- Assist Clinical Manager with on boarding/training new staff of EMR system, currently Netsmart
- Developed training materials to educate staff on best practices in clinical documentation.
- Implemented quality assurance processes to ensure consistency in documentation across departments.
- Led initiatives to streamline documentation workflows, reducing errors and improving efficiency.
- Conducted audits of clinical records, identifying areas for improvement and providing actionable feedback.
- Facilitated interdisciplinary collaboration between physicians, nurses, case managers, coders, and other relevant stakeholders regarding the appropriate representation of patient severity levels within EHRs.
- Analyzed data from audits to identify areas for improvement in clinical documentation processes, implementing targeted interventions for positive change.
- Reduced risk exposure by promptly addressing any identified discrepancies or inconsistencies within patient records.
- Assisted in the development of policies and procedures related to clinical documentation processes, promoting consistency across the organization.
- Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
- Effectively managed multiple priorities while maintaining strict adherence to established deadlines, ensuring the consistent delivery of exceptional clinical documentation services.
- Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
- Played an integral role in the successful implementation of new EHR software, providing valuable input during system design phases and facilitating seamless transition periods for all involved parties.
- Managed electronic clinical documentation and uploaded changes or updates using [Software].
- Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
- Ensured compliance with regulatory standards and guidelines through meticulous attention to detail in completing clinical documentation tasks.
- Participated in continuous education programs, staying up-to-date on industry trends and best practices in clinical documentation management.
- Served as a resource for healthcare professionals seeking guidance on various aspects of clinical documentation, fostering effective communication among team members.
- Improved clinical documentation quality by conducting thorough reviews and providing feedback to healthcare providers.
- Supported facility-wide efforts towards achieving high-quality performance metrics through comprehensive chart analysis focused on necessary improvements.
- Processed records quickly to avoid delays and keep workflows running smoothly.
Home Health Senior Clinical Documentation Specialist (QARN)
ARC Home Health Care. Good Samaritan Society
Denton, Texas
03.2020 - Current
- Utilization review for 50+ patients to determine medical necessity and appropriate plan of care.
- Review OASIS assessments and care plans for completion, accuracy, and compliance.
- Educate staff on OASIS and diagnosis coding.
- Assure accuracy of 485/POC within 5 days of admission.
- Responsible for processing orders for physician signature.
- Efficient in OASIS export.
- Increased patient outcomes from 2 Stars to 4.5 Stars at end of year 2021.
Home Health Clinical Manager
ARC Home Health Care. Good Samaritan Society
Denton, Texas
05.2019 - 03.2020
- Nursing knowledge to drive quality improvement initiatives and ensure that nursing practices in the agency are evidence based.
- Coordinate efforts with other disciplines, maximize reimbursements while controlling costs and ensure compliance with regulatory standards.
- Empower staff, Maintain healthy work environment, provide support, manage conflict and act as a role model.
- Promoting a positive image for long term care nursing by developing professional partnerships outside of the agency and reaching out to community resources.
- Led clinical operations, ensuring adherence to regulatory standards and best practices in home health care.
- Coordinated multidisciplinary team meetings, fostering collaboration among healthcare professionals for optimal patient outcomes.
- Evaluated patient care plans, adjusting strategies based on individual needs and feedback from caregivers.
- Established relationships with community resources, facilitating access to additional support services for patients and families.
- Mentored junior staff members, providing guidance on clinical best practices and professional development opportunities.
- Collaborated with physicians to develop customized treatment plans that addressed patients'' unique medical needs and goals.
- Enhanced interdisciplinary communication by initiating weekly team meetings, fostering collaboration among healthcare professionals.
- Ensured compliance with federal and state regulations through regular audits of clinical practices and documentation.
- Evaluated staff performance through regular assessments, providing constructive feedback for continuous improvement opportunities.
- Developed a robust referral network by establishing and maintaining relationships with key community partners, resulting in increased patient referrals.
- Mentored new clinicians during their onboarding process, offering guidance on best practices in home health management.
- Served as a liaison between the clinical team, management, and other departments to facilitate seamless coordination of services.
- Established and maintained effective communication with staff, physicians and community organizations to promote high quality patient care.
- Recruited, hired and trained all staff, providing direct supervision, ongoing staff development and continuing education to employees.
Registered Nurse Case Manager
ARC Home Health. Good Samaritan Society
Denton, Texas
09.2017 - 05.2019
- Managed care to over 30 patients, adjusting care plan and treatment
- Performed admits/discharges of patients, OASIS documentation and knowledgeable of Netsmart.
- Initiated and developed the patients care plan with established goals based on nursing diagnosis.
- Incorporated therapeutic, preventive, and rehabilitative care.
- Obtained and executed physician orders for wound care, IV infusions, and phlebotomy.
- Teaching/education to patient/families regarding disease process and medications
- Performed tasks with a patient centered focus.
- Ensured HIPPA Compliance.
- Coordinated patient care plans to meet individual health needs and optimize outcomes.
- Conducted comprehensive assessments to evaluate patient conditions and establish effective interventions.
- Collaborated with multidisciplinary teams to facilitate communication and enhance service delivery.
- Monitored patient progress, adjusting care strategies based on evolving health status and treatment goals.
- Developed educational materials for patients and families to promote understanding of health management strategies.
- Mentored junior nurses on best practices in case management and patient advocacy techniques.
- Collaborated with physicians and other healthcare providers to ensure appropriate resource utilization for complex cases.
- Evaluated healthcare needs, goals for treatment, and available resources of each patient and connected to optimal providers and care.
- Streamlined care coordination processes to reduce hospital readmissions and emergency department visits.
- Participated in on-call rotations to deliver after-hours care.
- Conducted comprehensive assessments of patients'' physical, emotional, and social needs in order to develop individualized care plans that facilitated optimal health outcomes.
- Enhanced interdisciplinary team communication through regular case conferences, promoting effective collaboration for optimal patient care.
- Responded promptly and professionally to patient questions and concerns.
- Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
- Effectively communicated with physicians regarding patient needs, performance, medications and changes.
- Participated in patient and family planning process, as well as provided instructions and addressed question and concerns.
- Authored clinical notes and updates to be reviewed by patient's primary physician.
- Administered medications and treatments as prescribed by physicians.
- Completed initial assessments of patients and family to determine and address individual home care needs. ·
- Developed care plans based on nursing diagnosis and incorporated therapeutic, preventive and rehabilitative nursing methods.
- Conducted regular re-evaluations to address changes in needs and conditions, introducing revisions to care plans.
- Administered physical examinations and documented history of current and previous conditions, illnesses and injuries.
- Developed professional relationships with community partners to enhance available support services for patients transitioning from acute care settings.
- Worked with suppliers and vendors on provision of medical equipment, items and services.
- Created patient assessments and plans for individual home care needs.
- Advocated for patients'' rights, facilitating access to necessary services and resources within the community.
- Coordinated with interdisciplinary professionals to develop plans of care, administer tests and monitor patient status.
- Reduced unnecessary medical interventions by monitoring high-risk patients closely, intervening as needed based on clinical expertise.
- Assessed and examined patients and documented history of current and previous conditions, diseases and injuries along with medications currently being taken.
- Examined patients and documented history of current and previous conditions, illnesses, injuries, and current medications.
- Performed evaluations on consistent basis to address changes in patient needs, conditions and medications, altering care plans when required.
- Negotiated with suppliers and vendors to procure medical equipment, supplies and services.
- Managed support services and fostered communication among social workers, therapists, hospital staff, and patients.
- Educated patients and caregivers on healthcare protocols and processes.
- Implemented care plans for patient treatment after assessing physician medical regimens.
- Observed and documented patient factors such as diets, physical activity levels, and behaviors to understand conditions and effectively modify treatment plans.
Registered Nurse
Denton Heart Group
Denton, Texas, United States
04.2014 - 06.2017
- Met clinical and organizational needs in a reliable and flexible manner for a cardiology office consisting of six Physicians.
- Assisted physician during clinical hours, gathering data, documenting.
- Maintained accurate records of patient care, condition, progress and concerns.
- Liaised between patients and physicians to ensure patient comprehension of treatment plans.
- Oversaw and managed 10 clinical and support staff in patient care activities while maintaining a high level of staff morale and professionalism.
- Initiated operations improvements to improve overall call center productivity
RN, Charge nurse, Staff nurse
Denton Regional Medical Center
Denton, TX
06.2006 - 04.2014
- Strong leader for nursing personnel assigned to the unit/shift as a charge nurse.
- Trained new staff, nursing graduates, and nursing students.
- Effectively managed clinical oversight for 29 bed unit in CVCU and ICU.
- Diagnosed and treated patients with chronic and acute health problems such as CAD, MI, arrhythmias, asthma, COPD and pneumonia, post op care for heart valve replacements and coronary artery bypass surgeries.
- Pharmacological and non-pharmacological management and treatment of various disorders and diseases.
- Liaised between patients and physicians to ensure patient comprehension of treatment plans.
- Additional work history upon request.
Education
Associate of Science - Nursing
Amarillo College
Amarillo, TX05.2001
Skills
- Documentation compliance
- Documentation improvement
- Process improvements
- Proficient in Home Care Home Base, Netsmart, Excell, Share point
- Teamwork and collaboration
- Decision-making skills
- Self motivation
Certification
- COS-C OASIS Specialist [2024-2027]
Timeline
Remote Senior Clinical Documentation Specialist (QARN)
Good Samaritan Society Home Health
03.2020 - Current
Home Health Senior Clinical Documentation Specialist (QARN)
ARC Home Health Care. Good Samaritan Society
03.2020 - Current
Home Health Clinical Manager
ARC Home Health Care. Good Samaritan Society
05.2019 - 03.2020
Registered Nurse Case Manager
ARC Home Health. Good Samaritan Society
09.2017 - 05.2019
Registered Nurse
Denton Heart Group
04.2014 - 06.2017
RN, Charge nurse, Staff nurse
Denton Regional Medical Center
06.2006 - 04.2014
Associate of Science - Nursing
Amarillo College