Ludwig Roesler
Palm Bay
Summary
Diligent clinical scribe with background in accurately documenting patient information during medical examinations. Possess strong knowledge of medical terminology, adept at listening and transcription skills. Demonstrated ability to work effectively and harmoniously with healthcare team contributing towards improved operational efficiency. Notable for prioritizing tasks, multitasking and maintaining confidentiality of patient records.
Overview
6
6
years of professional experience
2019
2019
years of post-secondary education
1
1
Certification
Work History
Clinical Scribe
Brevard Geriatrics
Palm Bay
03.2020 - Current
- Documented patient encounters and medical histories for provider review.
- Assisted healthcare providers during patient examinations and procedures.
- Maintained accurate and timely electronic health records in the system.
- Streamlined documentation processes to enhance workflow efficiency.
- Facilitated communication between patients and medical staff regarding treatment plans.
- Prepared and organized charts for upcoming patient appointments and visits.
- Managed confidential patient information according to legal and ethical standards.
- Maintained confidentiality of patient information in accordance with HIPAA regulations.
- Maintained confidentiality of all patient information in accordance with HIPAA regulations.
- Collaborated with interdisciplinary teams to ensure comprehensive patient care.
- Attended meetings related to clinical operations as requested by management.
- Communicated effectively with both internal and external customers including patients, families, physicians, nurses and other healthcare personnel.
- Answered phone calls promptly and professionally while providing excellent customer service.
- Transcribed physician orders accurately and efficiently.
- Initiated referrals for specialty services when appropriate.
- Responded quickly to any requests from physicians or nurses for additional information about a particular case.
- Provided support to healthcare providers by retrieving patient records from archives or other sources as needed.
- Assisted medical staff with electronic medical record documentation, patient history, and physical examination forms.
- Monitored incoming lab results for accuracy and completeness.
- Scheduled follow-up visits for patients after their initial appointment was complete.
- Ensured that the medical charts were up-to-date prior to any scheduled appointments.
- Performed data entry of patient information into the EHR system.
- Prepared summary reports for review by clinicians regarding patients' current status, treatments administered, medications prescribed.
- Observed physicians and clinical staff during examinations, surgeries, and other procedures to document patient care in real-time.
- Collaborated with nursing staff to ensure accurate charting of patient data.
- Noted physician instructions regarding changes in medication dosages or treatments.
- Checked in patients upon arrival at the clinic or hospital setting and collected necessary paperwork such as insurance cards, identification documents.
- Verified that all required tests were ordered prior to a procedure being performed on a patient.
- Input details about patient histories, physical examinations, medications and other information into physical or electronic charts.
- Followed clinicians throughout shift in high-volume, busy environments.
- Demonstrated knowledge of terminology for multiple medical specialties, consistently seeking ongoing training to expand and maintain knowledge base.
- Evaluated charts, documents and orders and made timely corrections.
- Reconciled clinical notes, patient forms and health information for compliance with HIPAA rules.
- Translated medical jargon and short-hand data into correct terminology.
- Informed doctor of urgent patient needs per nursing progress notes.
- Documented and initiated tests, scan and other orders.
- Monitored duration of basic lab results and screening procedures.
- Captured and transcribed medical record documentation with electronic medical record applications.
- Checked in patients to collect contact, medical and insurance information.
- Entered laboratory and radiology results into electronic medical records (EMR) systems.
- Monitored and updated patients' electronic health records (EHR) to reflect current diagnoses and treatments.
- Prioritized and managed multiple tasks simultaneously in a high-pressure environment.
Education
James Madison Highschool
Norcross, GASome College (No Degree) - Nursing
Eastern Florida State College
Cocoa, FLSkills
- Electronic health records
- Patient interaction
- Medical transcription
- Chart preparation
- CPR certified
- Computer skills
Certification
- CPR
Accomplishments
- Deans list
Timeline
Clinical Scribe
Brevard Geriatrics
03.2020 - Current
James Madison Highschool
Some College (No Degree) - Nursing
Eastern Florida State College