Madalyn Lee
Christus Imperial Calcasieu Surgical Center
Lake Charles,US
1
Certification
7
years of professional experience
Detail-oriented Registered Nurse (BSN) with 5+ years of clinical experience. Experienced with clinical documentation and ensuring accurate and compliant medical records. Proven ability to adapt quickly to new EMR systems and uphold strict HIPAA and regulatory standards. Seeking to leverage strong clinical knowledge, critical thinking, and chart review skills to improve the accuracy and quality of clinical documentation.
Work History
Registered Nurse - Outpatient Surgery Center
3 Years 4 Months- Conducted detailed evaluations of patient charts, integrating histories, comorbidities, prior procedures, diagnostic tests, pediatric assessments, and medication reconciliations to enhance surgical outcomes.
- Executed extraction and validation of critical clinical data to ensure surgical readiness.
- Conducted thorough monthly audits of charts to evaluate documentation integrity and adherence to established quality benchmarks.
- Evaluated comprehensive medical data, including laboratory results and specialty consults, to assess patient risk factors and contraindications for treatment.
- Ensured meticulous documentation accuracy in SIS while overseeing high patient volumes in a dynamic perioperative environment.
- Facilitated collaboration among surgeons, anesthesia providers, and interdisciplinary teams to ensure seamless clinical data exchange.
- Maintained strict adherence to HIPAA regulations and data privacy protocols to safeguard patient information.
Registered Nurse - Medical Surgical Unit
1 Year 3 Months- Managed care for patients with complex, multi-system medical conditions including cardiovascular, neurologic, metabolic, and post-surgical complications.
- Analyzed daily provider documentation, diagnostic reports, and care plans to ensure clinical accuracy and continuity of care.
- Documented comprehensive assessments and interventions in Paragon EMR systems.
- Identified clinical trends and changes through detailed chart review and interdisciplinary communication.
- Supported adult patient populations within a high-acuity inpatient setting.
Education
Bachelor of Science in Nursing - Nursing
Skills
Clinical documentation review
Medical record auditing
Documentation accuracy
EMR/EHR proficiency
High-Volume Workflow Management
Disease process knowledge
Clinical assessment
Quality Assurance & Compliance
HIPAA & Data Security
Cross-Functional Collaboration
Rapid Technology Adaptation
Medication and IV administration
Certification
- Registered Nurse (RN), Compact Multistate License – Louisiana (Active & In Good Standing)
- BLS | ACLS | PALS | CPR certified
Timeline
Registered Nurse - Outpatient Surgery Center
Christus Imperial Calcasieu Surgical Center
03.2023 - CurrentRead More
Registered Nurse - Medical Surgical Unit
Lake Charles Memorial Hospital
12.2019 - 03.2021Read More
McNeese State University
Bachelor of Science in Nursing from Nursing
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