Tracy Sammes
Hermon,ME
Summary
Proficient Clinical Documentation Specialist facilitating positive changes to documentation through close collaboration with healthcare providers. Analysis-oriented professional with strong organizational, time management, judgement, and critical thinking skills. Consistently finding ways to improve workflows and processes. Ability to handle multiple projects simultaneously with a high degree of accuracy.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Clinical Documentation Specialist
Children's Hospital Of Colorado
04.2014 - Current
- Reviews concurrent medical record documentation to assign and monitor DRG assignment and provide a complete representation of the patient's accurate acuity.
- Identifies opportunities to clarify documentation through identification of complications and comorbidities, procedures, and the application of the official coding guidelines for accurate code capture, specificity, and sequencing.
- Composes compliant queries with appropriate clinical evidence from the record to request documentation clarification from providers.
- Effectively inputs pertinent data, clinical evidence, critical thought processes into the CDI program to ensure accurate and complete data output through reporting of CDI program metrics and other data
reporting systems. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review. - Collaborates with the HIM coding team to support shared understanding and education to promote complete and accurate clinical documentation and correct negative trends.
- Participates in the education for physicians, nurse practitioners, case managers, coders, and other members of the interdisciplinary team members to facilitate comprehensive medical record documentation to reflect pertinent clinical evidence to support the diagnoses, treatment, and medical decision making appropriate for each admission.
- Facilitates modification to clinical documentation to support the clinical picture, risk of mortality and severity of illness rendered to all inpatients.
- Participates in team projects and ad hoc department projects to support the advancement of the CDI program with national best practice standards and adoption of innovative technologies.
- Reviews denial cases and drafts appeals with relevant citations from the clinical chart and appropriate clinical references to support argument.
- Collaboration with CDI and Coding leadership to communicate trends and necessary action plans. Collaboration with physician leaders to strengthen the appeal strategy.
Clinical Documentation Specialist
Centura Health
07.2012 - 04.2014
- Reviewed concurrent medical record documentation to assign and monitor DRG assignment and provide a complete representation of the patient's accurate acuity.
- Identified opportunities to clarify documentation through identification of complications and comorbidities, procedures, and the application of the official coding guidelines for accurate code capture, specificity, and sequencing.
- Composed compliant queries with appropriate clinical evidence from the record to request documentation clarification from providers.
- Effectively input pertinent data, clinical evidence, critical thought processes into the CDI program to ensure accurate and complete data output through reporting of CDI program metrics and other data
reporting systems. - Collaborated with the HIM coding team to support shared understanding and education to promote complete and accurate clinical documentation and correct negative trends.
- Participated in the education for physicians, nurse practitioners, case managers, coders, and other members of the interdisciplinary team members to facilitate comprehensive medical record documentation to reflect pertinent clinical evidence to support diagnoses, treatment, and medical decision making appropriate for each admission.
- Facilitated modification to clinical documentation to support the clinical picture, risk of mortality and severity of illness rendered to all inpatients.
Participates in team projects and ad hoc department projects to support the advancement of the CDI program with national best practice standards and adoption of innovative technologies.
Registered Nurse, PACU
Swedish Medical Center
09.2008 - 07.2012
- Roles include, but not limited to, caring for patients in the acute phases of post-operative recovery, with consideration of chronic health conditions and trauma, in a Level I trauma center.
- Stepping in to resolve emergent situations as they arise.
- Managing the flow of patients into the PACU, and RNs as the relief Charge RN, troubleshooting issues as they arise, and being a resource for other RNs.
Registered Nurse, Intensive Care Unit
Centura Health
05.2008 - 03.2010
- Managing, organizing, and providing direct patient care to medically complex critically ill patients, incorporating clinical decision-making, and prioritizing activities.
- Conducting comprehensive assessments, administering medications per protocol, and identifying treatment pathways.
- Performing and documenting ongoing assessments including observation, physical examination, laboratory/test results, and patient response to procedural interventions.
- Assisting other staff in the delivery of patient care, as appropriate.
Registered Nurse, ICU
New Britain General Hospital
12.2005 - 03.2007
- Managing, organizing, and providing direct patient care to medically complex critically ill patients, incorporating clinical decision-making, and prioritizing activities.
- Conducting comprehensive assessments, administering medications per protocol, and identifying treatment pathways.
- Performing and documenting ongoing assessments including observation, physical examination, laboratory/test results, and patient response to procedural interventions.
- Assisting other staff in the delivery of patient care, as appropriate.
Ceramic Engineer and Group Leader
Acumentrics Corporation
2000 - 2002
- Undertaking research and development programs in the area of ceramic and chemical engineering for Solid Oxide Fuel Cells, and related projects.
- Managing a group of ceramic engineers, technologists, and technicians.
- Reporting directly to the Director of the research program.
- Reporting via monthly written reports and meetings regarding research milestones.
- Problem solving related to research and development projects.
Education
Post-Baccalaureate Certificate in Basic Nursing - Nursing
University of Connecticut
Storrs, CT12.2005
Master of Science - Materials And Process Engineering
University of Waikato
Hamilton, New Zealand1999
Bachelor of Science - Materials And Process Engineering
University of Waikato
Hamilton, New Zealand1997
Skills
- Skilled in Epic, Optum, 3M 360, Meditech, Cerner, Microsoft Word, Office, Excel
- Medical Terminology
- Professionalism
- Documentation compliance
- Process Improvements
- Chart management
- Organizational abilities
- Attention to detail
- Teamwork and Collaboration
- Self-Motivation
- Multitasking
- Time Management
- Analytical Skills
- Effective Communication
- Problem-solving abilities
- Adaptability and Flexibility
- Patient chart auditing ability
- Organizational Skills
Accomplishments
- Collaborated with software company to help build an improved process for CDI workflow.
- Member of Sigma Theta Tau, International, Honor Society of Nursing
- Chair of the Engineering Students Conference, 1998 and 1999
- Editor of Conference Proceedings for the Engineering Students Conference, 1998 and 1999
- Publications: "Weak Link Scaling Analysis of High Strength Carbon Fiber", Composites, Part A - Applied Science and Manufacturing, 30 (8), 1999, pp 1017-1021, with Kim Pickering
- "Analysis of the Strength-Length Relationship of High Strength Carbon Fiber", Proceedings 1997 IPENZ Conference, Wellington, New Zealand, 7-10 February 1997, Volume 2, pp 342-347, with Kim Pickering
Affiliations
- Sigma Theta Tau
Certification
CCDS
Additional Information
References available on request
Timeline
Clinical Documentation Specialist
Children's Hospital Of Colorado
04.2014 - Current
Clinical Documentation Specialist
Centura Health
07.2012 - 04.2014
Registered Nurse, PACU
Swedish Medical Center
09.2008 - 07.2012
Registered Nurse, Intensive Care Unit
Centura Health
05.2008 - 03.2010
Registered Nurse, ICU
New Britain General Hospital
12.2005 - 03.2007
Ceramic Engineer and Group Leader
Acumentrics Corporation
2000 - 2002
Post-Baccalaureate Certificate in Basic Nursing - Nursing
University of Connecticut
Master of Science - Materials And Process Engineering
University of Waikato
Bachelor of Science - Materials And Process Engineering
University of Waikato
CCDS
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