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Jessica Claire
Montgomery Street, San Francisco, CA 94105
Home: (555) 432-1000 - Cell: - resumesample@example.com - -
Professional Summary

Reliable individual capable of interacting with practitioners and healthcare providers to ensure properly completed medical records. Bilingual Clinical Documentation Specialist with 3 years of experience recognizing and implementing methods that improve the medical records process.

Skills
  • Documentation compliance
  • Report generation
  • Medical Terminology
  • Clinical documentation management
  • Minor surgery assistance awareness
  • Medical laboratory procedures
  • Clinical judgment
  • Microsoft(Word, Excel, PowerPoint)
Work History
01/XXX0 to Current
Clinical Documentation Specialist Amita Health Wauwatosa, WI,
  • Protected patients from infection by setting up and managing sterile operating fields.
  • Kept views unobstructed by retracting, sponging and suctioning surgical sites.
  • Minimized surgical bleeding with skilled ligation and clamping of blood vessels.
  • Arranged supplies and instrumentation to meet needs of individual surgeons and enhance team efficiency.
  • Gowned and gloved staff to help team prepare for surgeries.
  • Applied antiseptics and sterile dressings to cover surgical locations and boost healing.
  • Identified and resolved process issues to encourage smoother procedures, more efficient workflow and overall business growth.
  • Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
  • Communicated with healthcare staff, including physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
  • Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
  • Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
  • Built and deployed plans, reports, validation procedures and entry processes for data management needs.
  • Evaluated patient care needs, prioritized treatment, and maintained patient flow.
  • Cooperated and communicated effectively with physicians to ensure client satisfaction and compliance with set standards.
  • Collected blood, tissue and other laboratory specimens and prepared for lab testing.
  • Analyzed patient and family feedback to identify opportunities for staff recognition as well as areas for improvement.
  • Confidently directed overall operation of nursing services and patient care, including financial management, quality assurance, patient care, safety risk management, teammate satisfaction, quality index scores and facility maintenance.
07/2019 to 08/2019
First Surgical Assistant Amita Health Williamsport, IN,
  • Arranged supplies and instrumentation to meet needs of individual surgeons and enhance team efficiency.
  • Kept views unobstructed by retracting, sponging and suctioning surgical sites.
  • Minimized surgical bleeding with skilled ligation and clamping of blood vessels.
  • Quickly responded to emergency situations during procedures with life-saving aid.
  • Applied antiseptics and sterile dressings to cover surgical locations and boost healing.
  • Protected patients from infection by setting up and managing sterile operating fields.
  • Accurately documented all elements of nursing assessment, treatments, medications, discharge instructions, and follow-up care.
  • Cooperated and communicated effectively with physicians to ensure client satisfaction and compliance with set standards.
  • Treated patients with strokes, head traumas, comas.
08/2017 to 07/2019
Medical Scribe Conway Regional Medical Center Greenbrier, AR,
  • Scanned and filed medical records in alphabetical order to maintain organized and up-to-date filing system.
  • Verified signatures and checked medical charts for accuracy and completion.
  • Submitted orders for additional tests and examinations.
  • Reviewed outpatient records and interpreted documentation to identify all diagnoses and procedures.
  • Accompanied physicians through day in fast-paced, stressful environments.
  • Processed paperwork such as discharges and transportation orders to coordinate patient movements.
  • Documented complete information about examinations, treatment plans, lab results and other details directly into charts.
  • Stayed on top of current patient loads to facilitate efficient and organized workflow.
  • Accepted dictated notes and produced professional documents with outlined information.
Education
Expected in 12/2011
M.D.: Medicine
Kabir Medical College - Gandhara University, Peshawar,
GPA:

Bachelor of Medicine & Bachelor of Surgery (MD) Doctor of Medicine

Certifications
  • Permanent RMP ( Registry of Pakistan Medical and Dental Council Government of Pakistan )

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Resume Overview

School Attended

  • Kabir Medical College

Job Titles Held:

  • Clinical Documentation Specialist
  • First Surgical Assistant
  • Medical Scribe

Degrees

  • M.D.

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