Tracy Butze

Carefully review patient files for clarity on diseases, diagnoses and procedures to determine quality of care.

Question Physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.

Obtain CDIS Certification

• Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
• 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.
• Managed electronic clinical documentation and uploaded changes.
• Education classes with Mid-level providers and residents to explain documentation skills.
• 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.

• Administered different therapies and medications in line with physician orders and treatment plan.
• Educated patients and answered questions about health condition, prognosis and treatment.
• Communicated openly and collaboratively with all healthcare staff to organize successful patient care.
• Trained new nurses in proper techniques, care standards, operational procedures and safety protocols.
• Answered codes quickly and orchestrated efficient, skilled medical care.
• Administered medications via oral, IV and intramuscular injections and monitored responses.
• Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
• Updated patient charts with data such as medications to keep records current and support accurate treatments.
• Advocated for and strived to protect health, safety and rights of patient.

• Recorded all patient discussions and transactions in charts for future reference.
• Educated patients on such topics as nutrition, medication side effects and proper skin treatments after radiation.
• Cultivated warm and compassionate atmosphere for patients receiving chemotherapy and radiation.
• Assessed patients during course of treatment to identify concerning reactions.
• Completed initial examinations and intake questions for each appointment.
• Educated family members and caregivers on patient care instructions.
• Worked as a weekend employee.

• Implemented care plan, coordinated delivery and employed strategies to promote health and safe environment.
• Conducted telephone triage to patient, family and significant others using nursing judgment according to protocol.
• Managed patients with multiple chronic health conditions, acute episodes of care and behavioral health challenges while promoting and supporting prevention and wellness.
• Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
• Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.

Ran the health clinic grades K-12 depending on what building I was assigned.

Administered insulin, tube feedings and all medications to students.

Responded to all building emergencies involving staff or students.

Administered Epi pens to students having allergic reactions.

Served as a health educator to staff and students.

Kept health records in order.

• Conducted telephone triage to patient, family and significant others using nursing judgment according to protocol.
• Managed patients with multiple chronic health conditions, acute episodes of care and behavioral health challenges while promoting and supporting prevention and wellness.
• Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.

• Educated patients and families on medical-surgical procedures, therapeutic regimens and pain management techniques.
• Monitored patients before and after surgical operations.
• Administered blood products, IV medications, Oral Medications.
• Maintain ACLS and CPR certifications
• Started intravenous fluids, administered medications and documented patient charts by recording food and fluid output and intake.
• Managed patients' pain by implementing pharmacological and non-pharmacological pain management interventions.
• Provided exceptional care to high-acute patients needing complex care such as managing drains, extensive wound care and rehabilitation.