Sara Roberts
North Tonawanda,NY
Summary
Accomplished Clinical Documentation Specialist and Registered Nurse at Erie County Medical Center Corporation, ECMCC, adept in documentation compliance and fostering exemplary communication. Spearheaded process improvements, enhancing clinical documentation accuracy and patient care quality. Skilled in 3M Solventum and mentoring, demonstrating exceptional organizational abilities and teamwork, significantly contributing to revenue optimization and risk reduction.
Overview
24
24
years of professional experience
Work History
Clinical Documentation Specialist
Erie County Medical Center Corporation, ECMCC
2018.10 - Current
- Facilitated interdisciplinary collaboration between physicians, nurses, case managers, coders, and other relevant stakeholders regarding the appropriate representation of patient severity levels within EHRs.
- Analyzed data from audits to identify areas for improvement in clinical documentation processes, implementing targeted interventions for positive change.
- Expedited accurate clinical documentation completion by promptly responding to queries from healthcare providers and support staff, offering timely guidance and support.
- Reduced risk exposure by promptly addressing any identified discrepancies or inconsistencies within patient records.
- Assisted in the development of policies and procedures related to clinical documentation processes, promoting consistency across the organization.
- Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
- Effectively managed multiple priorities while maintaining strict adherence to established deadlines, ensuring the consistent delivery of exceptional clinical documentation services.
- Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
- Contributed to revenue optimization by identifying opportunities for appropriate clinical documentation improvement.
- Served as a resource for healthcare professionals seeking guidance on various aspects of clinical documentation, fostering effective communication among team members.
Registered Professional Nurse
Erie County Medical Center Corporation, ECMCC
2000.07 - 2018.10
- Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
- Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.
- 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.
- Assisted in the training and mentorship of new nursing staff members, contributing to a positive work environment and high-quality patient care.
- Prevented the spread of infections by consistently adhering to strict infection control protocols and educating patients on proper hygiene practices.
- Collaborated with interdisciplinary teams to develop comprehensive treatment plans for complex patients with multiple comorbidities.
- Served as a preceptor for nursing students during their clinical rotations, providing valuable real-world experience and guidance to foster professional growth.
- Promoted a culture of safety within the healthcare facility by participating in quality improvement initiatives, identifying potential hazards, and advocating for best practices in nursing care delivery.
- Educated family members and caregivers on patient care instructions.
Education
Bachelor of Science - Nursing
D'Youville College
Buffalo, NY05.2000
Skills
- Process Improvements
- Training and mentoring
- Report creation
- Organizational abilities with strong attention to detail
- Teamwork and Collaboration
- Time Management
- Problem-solving and multi-tasking abilities
- Reliability
- Excellent Communication
Timeline
Clinical Documentation Specialist
Erie County Medical Center Corporation, ECMCC
2018.10 - Current
Registered Professional Nurse
Erie County Medical Center Corporation, ECMCC
2000.07 - 2018.10
Bachelor of Science - Nursing
D'Youville College
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