Dynamic Registered Nurse Abstractor with extensive experience at the West Virginia Department of Health and Human Resources. Proven expertise in clinical documentation and data entry, ensuring HIPAA compliance. Recognized for exceptional teamwork and attention to detail, contributing to quality improvement initiatives in maternal and infant health. Committed to enhancing patient care through effective communication.
Experienced with clinical data abstraction and patient care documentation. Utilizes analytical techniques to enhance data quality and streamline processes. Track record of effective communication with healthcare teams and maintaining high standards of accuracy.
Registered nursing professional with experience in healthcare data abstraction and patient care. Adept at analyzing medical records, ensuring accuracy, and maintaining confidentiality. Strong team player, adaptable to changing needs, and focused on achieving results. Skilled in clinical documentation, data management, and electronic health records. Reliable and collaborative, consistently delivering high-quality outcomes.
May 2021 to December 2022:
Review of medical records/chart abstraction for COVID-19 in pregnancy.
Create Microsoft excel spreadsheets for chart abstraction tracking and medical record requests.
Request medical records/patient charts from birth and death hospitals, pediatricians, and prenatal records.
Attended monthly meetings with CDC team.
Enter data that was abstracted from medical records into RedCap database.
December 2022 to Present Date:
Communicate with Vital Statistics to verify birth and death certificate information for mothers and infants.
Create Microsoft excel spreadsheets for chart abstraction tracking and medical record requests.
Request medical records/patient charts from birth and death hospitals, WV birth score, OCME, Newborn Screening program, CSHCN, BSS/CPS via fax/email/portals. Request prenatal records for mothers and pediatrician records for infants via fax/email/portals.
Download received medical records to the appropriate Google shared drive folders and update master chart request tracking excel spreadsheet.
Complete infant and/or mother medical record/chart abstraction review for infant (
Complete case narratives/summaries based on medical record review for mothers and/or infants.
Enter patient data that was abstracted from medical records into FIMR and/or MMRIA database.
Attend weekly meetings with IMMRP team.
Attend quarterly meetings with IMMRP team and panel members to discuss recommendations to prevent future infant and maternal deaths; prepare for these meetings in advance by answering any questions the IMMRP panel has.
Attend monthly meetings with CDC regarding maternal deaths/MMRIA database.
Actively communicate with IMMRP team members on a daily basis to discuss IMMRP chart abstraction progress.
Employed as a registered nurse and provided post anesthesia care to pediatric and adult patients which included the following:
Extubation of adult and pediatric patients once stable/awakening.
Medicated adult and pediatric patients for appropriate needs (pain, nausea, stabilization of vital signs) based on physician order.
Obtain/monitor vital signs (place on cardiac monitor) and provide stabilization if needed.
Perform basic/advanced nursing care to adult and pediatric patients (Foley catheter care, drain care, activities of daily living, surgical site care, IV site care, provide oral fluids/food based on clinical status)
Medical record/patient clinical documentation via electronic documentation system, including adult and pediatric physical assessments, plan of care, medications given via MAR, education, and nursing notes.
Assign Aldrete scores to patients via chart documentation based on clinical status in order to advance them to a lower level of care for discharge home or to be transferred to a regular hospital floor.
Received report from operating room staff (anesthesiologists, CRNAs) for transfer of patient care.
Gave report to floor/lower level of care staff for patient care handoff.
Transported patients to hospital floor for monitoring or to the lower level of care floor to be discharged.
Assigned/worked call out shifts in case of a surgical emergency during midnight hours and carried a pager during those shifts.
Employed as an RN on an outpatient orthopedic floor for patients that had total knee replacement, total hip replacement, and total shoulder replacement surgeries.
Obtained CPR/BLS certification.
Obtained PALS certification.
Obtained ACLS certification.
Assigned 2-3 patients during a shift. Completed clinical documentation on those patients with a medical record documentation system that included physical assessments, plan of care, physician orders, nursing notes, education, MAR administration.
Completed basic and advanced nursing care to adult patients such as monitoring of vital signs, toileting, feeding/diet needs, wound/surgical site care, insertion/discontinuation of IVs/Foley Catheters, discontinuation of wound drains (Hemovac, JP drains), etc.
Completed patient admission information including past medical history, medication reconciliation, create plan of care.
Provided healthcare education to the patient/family members regarding patient's plan of care.
Received/gave report to/from surgical/floor hospital staff for transfer of patient care.
Administered medications as ordered/needed to patients per physician orders.
Completed hospital rounding checklists during night shifts including condition of crash carts, OR rounding/temps, medication expiration dates, controls of glucose monitors, refrigeration temps, etc.
Completed turnover of patient rooms (basic cleaning).
Assembled paper charts for future patients to be used in pre-op/OR.
06/2015 to 05/2017:
Employed as a nurse extern during nursing school on a labor and delivery floor.
Performed basic care needs for laboring/postpartum/antepartum mothers such as monitoring of vital signs, hooking up to monitors (TOCO, EFM), activities of daily living, etc.
Occasionally was floated to the nursery/NICU floor to assist with basic care needs for the infants.
Assisted nursing staff with performing mother and infant care as needed, such as insertion of IVs, insertion of Foley catheters, preparing for c-sections, infant hearing screens, PKUs, etc.
05/2017 to 03/2020:
Employed as a RN/charge RN on an orthopedic/urology/surgical floor. Assisted patients that had general/urological surgeries (abdominal, thyroid, TURP, hysterectomy, etc), trauma surgeries (broken bones needing ORIF, etc).
Assigned 6-7 patients during a shift and completed clinical documentation (including physical assessments, plan of care, physician orders, nursing notes, education, MAR administration) on those patients within the Meditech system.
Completed basic and advanced nursing care to adult patients such as toileting, feeding/diet needs, wound care, insertion/discontinuation of IVs/NG tubes/Foley Catheters, discontinuation of PICC lines/wound drains (Hemovac, JP drains), suctioning, etc.
Assisted physicians with advanced care such as insertion of PICC lines, advanced wound care (I&Ds), etc.
Administered medications via oral, NG, IV, PICC, G tube routes as ordered/needed.
Completed admission/discharge information (including past medical history, medication reconciliation, create plan of care) and provided education to the patient/family. Received/gave report to/from EMS, hospital staff (ED/floor, ICU), nursing home/home health staff.
Spoke to various physicians and interdisciplinary team in regards to the patient's plan of care and distributed physician orders.
Occasionally floated to an outpatient orthopedic, cardiac, or respiratory floor to assist other staff/work load.
Trained new staff (RNs, LPNs) that were new graduates or had previous nursing experience assisted them with adult patient assignments/care and clinical documentation including plan of care.
Supervised nursing and non-clinical staff (CNAs, LPNs, RNs, Unit clerks) as the medical surgical floor charge nurse for the shift (average supervision of 5-7 employees per shift-depending on patient workload and available staff for that particular shift) beginning in 05/2018.
Assigned adult patient assignments to staff as they were admitted from the ED or a direct admit and for the following shift.