Proficient Clinical Documentation Specialist knowledgeable in evaluating medical records to determine accuracy and overall care quality. Talented professional with background in medical terminology, coding and team collaboration.
Overview
24
24
years of professional experience
1
1
Certification
Work History
Clinical Documentation Specialist
Parkland Hospital
10.2013 - Current
Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
Verified accuracy and overall completeness of medical records by auditing and reviewing patient information.
Registered Nurse
Parkland Hospital
11.2009 - 10.2013
Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
Provided direct patient care, stabilized patients, and determined next course of action.
Registered Nurse
UT SOUTWESTERN
06.2008 - 11.2009
Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
Administered medications via oral, IV, and intramuscular injections and monitored responses.
Administered medications and treatment to patients and monitored responses while working with healthcare teams to adjust care plans.
Registered Nurse
CHW Hospital
05.2006 - 06.2008
Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
Administered medications via oral, IV, and intramuscular injections and monitored responses.
Staff Nurse/Clinical Educator
Lal Memorial Hospital
12.1999 - 01.2006
Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.
Administered medications via oral, IV, and intramuscular injections and monitored responses.
Assessed physical, psychological, physiologic, and cognitive status of patients.
Monitored patients' conditions and reported changes in physical presentation, appearance, and behavior to discuss treatment with physicians.
Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.