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Clinical Documentation Specialist Resume Example

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Jessica Claire
  • , , 100 Montgomery St. 10th Floor
  • H: (555) 432-1000
  • C:
  • resumesample@example.com
  • Date of Birth:
  • India:
  • :
  • single:
Professional Summary

Diligent Nursing professional with demonstrated success in emergency patient care. Agile and responsive to dynamic patient needs and environmental conditions. Team-oriented and reliable with expert healthcare knowledge, clear verbal and written communication skills and sound clinical judgment.

Skills
  • Experienced critical care nurse
  • Tracheostomy Care and Ventilator management
  • Chronic disease management
  • Infection control measures
  • Medication and IV administration
  • Proficient in EPIC, Iodine, JATA
  • Medical record review, DRG assignment
  • Exemplary communication skills
  • Self-motivated professional
  • Patient education and cultural awareness
Skills
  • Experienced critical care nurse
  • :
  • Tracheostomy Care and Ventilator management
  • :
  • Chronic disease management
  • :
  • Infection control measures
  • :
  • Medication and IV administration
  • :
  • Proficient in EPIC, Iodine, JATA
  • :
  • Medical record review, DRG assignment
  • :
  • Exemplary communication skills
  • :
  • Self-motivated professional
  • :
  • Patient education and cultural awareness
  • :
    Work History
    Clinical Documentation Specialist, 09/2017 to 07/2020
    Trinity Health Corporation Red Hook, NY,
    • Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
    • Queried physicians regarding missing or unclear health record documentation requesting further documentation for clarification purposes.
    • Communicated with healthcare staff, including physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
    • Strong knowledge of medical terminology, diseases and conditions and procedures.
    • Reviewed charts and flagged incomplete or inaccurate information.
    Staff Nurse, Intensive Care Unit, 04/2015 to 09/2017
    Providence Holy Cross Medical Center City, STATE,
    • Delivered age-appropriate medical care for adult, adolescent and geriatric ICU patients.
    • Maintained respectful treatment environment that honored patients' and families’ cultural and religious traditions and preferences.
    • Explained health care issues and ramifications to patients and families to promote informed medical care choices.
    • Intensive Care Unit- Working cohesively with healthcare team to provide optimal patient care.
    • Delivered outstanding patient care in intensive care units. Skilled in caring for trauma patients including patients with ICP and external ventricular drainage (EVD).
    • Oversaw monitoring and care of invasive lines such as CVC and arterial catheters. Careful administration and monitoring of vasoactive drugs, titration, thrombolytic therapy, dysrhythmia interpretation and chest tubes.
    • Recorded patients' medical status and treatment details in electronic charts to accurately document medical care.
    • Performed various nursing interventions such as wound dressing, vital sign monitoring and specimen collection.
    RN Preadmission Testing and Teaching, 10/2012 to 03/2015
    WellStar Health System City, STATE,
    • Educated patients about surgeries and provided treatment plan documentation.
    • Reviewed medical histories and current information to provide accurate information to surgeons.
    • Preparing clients for upcoming surgery performing any pre-surgical testing .
    • Monitoring charts to ensure compliance with core measures as well as SCIP protocols.
    • Communicated with physicians offices to confirm patients medical histories and prevent inaccurate diagnoses and treatments.
    • Organized and managed care of patients undergoing various therapies and procedures.
    • Managed care from admission to discharge, including patient assessments, care planning, health educations and discharge support.
    Staff Nurse, Intensive Care Unit, 12/2009 to 01/2015
    Wellstar Health City, STATE,
    • Delivered age-appropriate medical care for adult, adolescent and geriatric ICU patients.
    • Explained health care issues and ramifications to patients and families to promote informed medical care choices.
    • Recorded patients' medical status and treatment details in electronic charts to accurately document medical care.
    • Maintained respectful treatment environment that honored patients' and families’ cultural and religious traditions and preferences.
    • Developed and implemented patient care plans based on physicians' instructions and generally accepted nursing practices.
    • Coordinated patients' post-discharge treatment plans with physicians and other nurses to promote continuity of medical care.
    • Oversaw various aspects of central line management. Monitoring CVC and arterial catheters, vasoactive drugs, titration, thrombolytic therapy, dysrhythmia interpretation, ventilator management and chest tubes.
    • Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process and management and lifestyle options.
    • Performed various nursing interventions such as wound dressing, vital sign monitoring and specimen collection.
    Education
    Bachelor of Science: Nursing, Expected in 06/2018
    to
    Western Governors University BSN - Salt Lake City, Utah,
    GPA:
    Associate Degree in Nursing: Nursing, Expected in 12/2006
    to
    Antelope Valley College - Lancaster, CA
    GPA:

    RN Program- Accredited by the State Board of Registered Nursing

    Certifications

    Recipient of the Wellstar Nursing Excellence Award

    Certifications/Training -Calif. RN License,-Georgia RN License, BLS, NIHSS, Fire Safety.

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    Resume Overview

    School Attended
    • Western Governors University BSN
    • Antelope Valley College
    Job Titles Held:
    • Clinical Documentation Specialist
    • Staff Nurse, Intensive Care Unit
    • RN Preadmission Testing and Teaching
    • Staff Nurse, Intensive Care Unit
    Degrees
    • Bachelor of Science
    • Associate Degree in Nursing