Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Paula Lewis

Jamaica

Summary

Dynamic Clinical Documentation Specialist with a proven track record at One Brooklyn Health, excelling in documentation compliance and process improvements. Leveraging exemplary communication skills and a strong grasp of medical terminology, I have successfully enhanced documentation quality, contributing to revenue optimization and improved patient care standards.


Overview

23
23
years of professional experience
1
1
Certification

Work History

Clinical Documentation Specialist

One Brooklyn Health
07.2016 - Current
  • Reviewed clinical documentation for accuracy and completeness.
  • Assisted in identifying discrepancies within patient records.
  • Supported compliance initiatives by ensuring adherence to regulatory standards.
  • Collaborated with healthcare providers to clarify documentation requirements.
  • Sent queries to physicians to clarify documentation
  • Reduced risk exposure by promptly addressing any identified discrepancies or inconsistencies within patient records.
  • Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
  • Contributed to revenue optimization by identifying opportunities for appropriate clinical documentation improvement.
  • Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
  • Contributed to training sessions on best practices for documentation processes.
  • Implemented feedback mechanisms to enhance documentation quality.
  • Maintained up-to-date knowledge of coding guidelines and policies.
  • Participated in interdisciplinary meetings to address documentation challenges.

Registered Nurse

Northwell Health Valley Stream Hospital
12.2002 - Current
  • Administered medications and treatments according to established protocols and patient care plans.
  • Collaborated with multidisciplinary teams to develop comprehensive patient care strategies.
  • Educated patients and families on health management, medication adherence, and post-discharge care.
  • Monitored vital signs and assessed patient conditions to identify changes in health status.
  • Mentored new nursing staff, providing guidance on clinical procedures and best practices.
  • Streamlined workflow processes to enhance patient care efficiency and resource utilization.
  • Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
  • Administered medications safely according to established guidelines while closely monitoring for side effects or adverse reactions requiring intervention.
  • Enhanced patient satisfaction by providing compassionate, holistic nursing care that addressed physical, emotional, and spiritual needs.
  • Prevented the spread of infections by consistently adhering to strict infection control protocols and educating patients on proper hygiene practices.

Quality Manager

Interfaith Medical Center
07.2009 - 06.2016
  • Led quality assurance initiatives to enhance patient care standards and compliance with regulatory requirements.
  • Developed and implemented quality management systems, ensuring adherence to best practices in healthcare delivery.
  • Conducted comprehensive audits and assessments, identifying areas for process improvement and risk mitigation.
  • Mentored staff on quality protocols, fostering a culture of continuous improvement and accountability within teams.
  • Analyzed data trends to inform strategic decisions and drive enhancements in patient safety measures.
  • Established performance metrics to evaluate effectiveness of quality initiatives, aligning them with organizational goals.
  • Managed root cause analysis investigations, determining underlying issues in product failures and implementing corrective actions as necessary.
  • Evaluated quality problems and performed assessments to identify and resolve issues.
  • Updated quality control standards, methods, and procedures to meet compliance requirements.
  • Improved quality processes for increased efficiency and effectiveness.

Education

No Degree -

Nassau Community College
Garden City, NY

No Degree - Nursing

St Joseph Mercy Hospital School of Nursing
Georgetown Guyana
03-1996

General Education

Christ Church
Georgetown Guyana
06-1980

Skills

  • Documentation compliance
  • Process improvements
  • Proficient in Excel, Powerpoint
  • Exemplary communication skills
  • Medical terminology

Certification

  • Licensed Registered Nurse
  • ACLS Certificate
  • BLS Certificate

Timeline

Clinical Documentation Specialist

One Brooklyn Health
07.2016 - Current

Quality Manager

Interfaith Medical Center
07.2009 - 06.2016

Registered Nurse

Northwell Health Valley Stream Hospital
12.2002 - Current

No Degree -

Nassau Community College

No Degree - Nursing

St Joseph Mercy Hospital School of Nursing

General Education

Christ Church

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