
Dedicated neonatal nurse with extensive experience managing critically ill neonates in high-pressure settings. Proven ability to enhance patient outcomes through accurate clinical documentation and strategic collaboration with multidisciplinary teams.
• Document detailed assessments, clinical indicators, and interventions for critically ill neonates.
• Manage patients requiring HFOV, HFJV, nitric oxide, mechanical ventilation, CPAP, and post-operative care.
• Collaborate with neonatology and multidisciplinary teams to ensure accurate and consistent documentation.
• Utilize Cerner for precise charting supporting coding and continuity of care.
• Worked in a level IV NICU with complex patients requiring precise, high‑acuity documentation.
• Ensured alignment between clinical findings, provider documentation, and EMR entries.
• Documented evolving clinical status using Epic.
• Provided comprehensive documentation for a large 84‑bed NICU.
• Recorded detailed respiratory support, congenital heart disease, metabolic instability, and feeding intolerance data.
• Tracked trends and clinical indicators in Epic to support coding accuracy.
• Ensured complete, clear documentation for neonates receiving advanced respiratory therapy and surgical interventions.
• Used Epic to maintain accurate records of labs, vital trends, and interventions.
CORE SKILLS
Clinical documentation accuracy
Identification of gaps or unclear diagnoses
Clinical judgment and interpretation of indicators
Interdisciplinary communication
Lab, imaging, and clinical trends interpretation
EMR proficiency: Epic & Cerner
Time management and prioritization
Independent and team‑based work