Clinical Documentation Specialist Resume Example Company Name

CLINICAL DOCUMENTATION SPECIALIST

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

01/2020 to Current

Clinical Documentation SpecialistCompany Name – City, State

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 AssistantCompany Name – City, State

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 ScribeCompany Name – City, State

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

12/2011

M.D.: Medicine
Kabir Medical College - City

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

Certifications

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

Voluntary Work

Research Associate/Medical Scribe August 2017 - July 2019 ( Stanaford Medical Clinic Beckley WV)
Received and greeted patients, took detailed history, recorded vitals and prepare them for detailed examination.

Collected data, identified triggering factors, discussed treatment goals, outcomes and counseled patients of the Suboxone program.

March 2016 - August 2017 (Beckley ARH )
First Surgical Assistant (Volunteered & Observed)
Voluntarily assisted and observed Eye surgeries and Vascular surgeries.
September 2015 - February 2016 - Clinical Observation/Shadowing (Beckley ARH Hospital)

Greeted and managed patients, prepared them for examination, observed the attending Cardiologist, and observed CAG.

November 2014 - May 2015
Tutor - Taught and helped nursing students understand subjects like Anatomy, Physiology, Pathology and Medicine.

Resume Overview

School Attended

Kabir Medical College

Job Titles Held:

Clinical Documentation Specialist
First Surgical Assistant
Medical Scribe

Degrees

M.D. : Medicine

Clinical Documentation Specialist Resume Example

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