Results-driven Medical Records Director with expertise in healthcare compliance and quality assurance. Proven ability to coordinate interdisciplinary care and enhance documentation practices, ensuring regulatory adherence and optimal patient outcomes.
Overview
19
19
years of professional experience
Work History
Medical Records Director
Lindsay Gardens Nursing and Rehabilitation
Lindsay, California
05.2015 - Current
Coordinated audits to ensure compliance with regulatory standards and best practices.
Collaborated with healthcare professionals to improve accuracy and completeness of documentation practices.
Managed organized system of closed and open medical records, ensuring timely access for interdisciplinary personnel.
Facilitated interdepartmental communication to streamline processes for patient records and data sharing.
Reviewed discharges and other records on nursing units for compliance with procedures.
Collected, checked, and organized resident charts and personnel records.
Returned incomplete records and charts to appropriate personnel for correction.
Rehab Coordinator
Sequoia Transitional Care
Porterville, California
01.2024 - 09.2024
Coordinated patient care plans with interdisciplinary teams for effective rehabilitation.
Managed therapy session scheduling to maximize resource utilization and enhance patient access to care.
Communicated with patients and families to provide updates on recovery progress.
Maintained accurate documentation of patient records in electronic health systems for tracking progress.
Actively participated in team meetings to discuss patient cases and coordinate interdisciplinary care planning efforts.
Facilitated communication among therapists and healthcare providers to ensure cohesive rehabilitative support for patients.
Verified accuracy of discharge documents to ensure compliance and smooth transition for patients leaving rehab unit.
Created staff schedules based on workload and resource availability. and staff assignments, taking workload, space and equipment availability into consideration.
CNA
Sierra Valley Rehab Center
Porterville, California
06.2007 - 09.2015
Monitored vital signs and reported changes to nursing staff.
Assisted patients with daily living activities and personal hygiene.
Documented patient care activities and observations accurately.
Communicated effectively with patients, families, and healthcare team members.
Answered call lights promptly and responded to patient needs accordingly.
Observed and reported unusual symptoms and changes to charge nurse.
Repositioned residents using proper body mechanics to prevent pressure ulcers and maintain skin integrity.
Responded quickly to emergency situations involving sudden illness or injury.