Sentences with phrase «medical chart documentation»

Child maltreatment was measured by examining child protective services reports using State agency data, medical chart documentation for possible abuse or neglect, and parental report of harsh punishment via the Parent - Child Conflict Tactics scale.

Assessed all new patients, kept detailed medical chart documentation and prioritized clinic schedules that allowed for quick response to all emergency patients.

Perform all medical chart documentation with physician oversight.

Streamlined medical chart documentation, resulting in 36 - month operating certificate (received in July 2015).

Not exact matches

Documentation of Injuries - Obtain your loved one's medical chart from the nursing home so that you can see exactly what treatment they were given.

Maintain patient dental charts including periodontal charting and documentation of medical histories

Work with internal business partners by rounding to obtain medical record documentation for patient charts upon discharge.

One example of documentation skills is medical charting for doctors and nurses.

Tender Loving Care • Burtonsville, MD 2005 — 2006 Data Entry Clerk Handled records management and ensured accuracy of patient records; created medical charts for new patients, filed all medical records and supplemental documentation.

Medical Coding Chart Auditing Clinical Documentation Improvement Support ICD - 10 Support Administrative & Clerical HIM FAQs

Cellnetix — Dudley, NC Medical Courier Aide 2001 — 2002 • Ensured counting and inventory of all medical items to be picked or dropped • Made sure that each piece was adequately secured in the transport vehicle • Arranged items along with proper documentation • Assisted medical courier in charting out appropriate routes to the destination • Handled waste management duties according to the company's prMedical Courier Aide 2001 — 2002 • Ensured counting and inventory of all medical items to be picked or dropped • Made sure that each piece was adequately secured in the transport vehicle • Arranged items along with proper documentation • Assisted medical courier in charting out appropriate routes to the destination • Handled waste management duties according to the company's prmedical items to be picked or dropped • Made sure that each piece was adequately secured in the transport vehicle • Arranged items along with proper documentation • Assisted medical courier in charting out appropriate routes to the destination • Handled waste management duties according to the company's prmedical courier in charting out appropriate routes to the destination • Handled waste management duties according to the company's protocols

Thorough understanding of chart documentation in the Electronic Medical Record and Lotus Notes.

• First - hand experience in creating and maintaining patients» records in accordance to facility policies and state regulations • Highly skilled in establishing records prior to patients» admission by creating master files for both admitted and discharged patients • Effectively able to collect information from nursing staff, therapists, patients and families and surgeons in order to complete existing records • Deeply familiar with retrieving and filing medical record jackets and documentation to and from central files • Well - versed in purging and archiving obsolete records by placing them in storage and maintaining storage logs • Especially well - versed in preparing new patient records by following set standards and protocols and maintaining existing ones • Proven record of effectively collecting data, compiling statistical information and preparing reports from medical records information charts • Hands - on experience in determining appropriate release of medical records and preparing correspondence and forms to respond to retrieval requests • Demonstrated expertise in establishing and upholding processes to be followed for collection, coding and indexing of medical records • Proficient in maintaining a detailed record of authorized information taken from medical records

CAROLINA MEDICAL CENTRE, Kingsport, TN (July 2011 — October 2013) Billing / Coding Officer • Verified code locations and charge entries • Maintained patient database and utilized it to extract data regarding medical services provided • Consulted with physicians for clarification regarding service details • Translated medical services into system appropriate coded data utilizing ICD - 9 and CPT guidelines • Worked with medical assistants to coordinate services details from patients medical charts • Communicated and rectified documentation discrepancies in medicalMEDICAL CENTRE, Kingsport, TN (July 2011 — October 2013) Billing / Coding Officer • Verified code locations and charge entries • Maintained patient database and utilized it to extract data regarding medical services provided • Consulted with physicians for clarification regarding service details • Translated medical services into system appropriate coded data utilizing ICD - 9 and CPT guidelines • Worked with medical assistants to coordinate services details from patients medical charts • Communicated and rectified documentation discrepancies in medicalmedical services provided • Consulted with physicians for clarification regarding service details • Translated medical services into system appropriate coded data utilizing ICD - 9 and CPT guidelines • Worked with medical assistants to coordinate services details from patients medical charts • Communicated and rectified documentation discrepancies in medicalmedical services into system appropriate coded data utilizing ICD - 9 and CPT guidelines • Worked with medical assistants to coordinate services details from patients medical charts • Communicated and rectified documentation discrepancies in medicalmedical assistants to coordinate services details from patients medical charts • Communicated and rectified documentation discrepancies in medicalmedical charts • Communicated and rectified documentation discrepancies in medicalmedical record

Skill Highlights Charting expertise Understands medical procedures Documentation procedures expert C...

Monitors all charting, medical and programming documentation.

schedule appointments, benefits, charts, CMS, Computer Literate, clientele, clients, data entry, database, Department of Health, documentation, EKG, filing, Health Education, injections, insurance, Marketing, Medical Manager, Excel, Power Point, Microsoft Word, Policies, protocols, quality, Quality Assurance, Research, service level agreements, answer phones, Phone, triage, Type, Typing, Venipuncture

accounts payable, Attorney, benefits, billing, call center, charts, conflict resolution, CPT4, client, Customer service, customer service skills, documentation, staff training, focus, government, ICD10, insurance, medical terminology, Office, policies, pricing, Coding, protocols, quality, vendor relations, verbal communication, Excellent written

• Gather individual's medical information and communicate individual needs to our Nurses and Health Services Manager • Attend and effectively and appropriately participate in medication reviews, medical chart audits, clinics and appointments • Monitor individuals, review records, and provide medical support at various locations within the Residential and Therapeutic Services department to assure an individual's needs are appropriately addressed • Communicate and consult with appropriate internal / external providers regarding medical needs and concerns; ensure appropriate information (med audits, health reviews, consult forms, etc.) is disseminated in a timely manner • Consult with the Nurses and Health Services Manager regarding coordination of medical, laboratory and dental care; follow up as required • In conjunction with approved staff, review Medication Administration Records and Physician Orders monthly to assure accuracy • Complete, review, and sign off on medical and health related documentation; complete paperwork and provide documentation for individuals» in services meetings • Provide educational in - services to agency staff in requested medical areas • Enter data and generate data base reports; track and distribute requested records and other information

Registered Nurse / Administrator — Duties & Responsibilities Provide quality patient care and medical team support across a variety of medical specialties Proficient with skillful assessment, planning, implementation, documentation and evaluation of treatment plans Skilled in telemetry, women's services, post-partum and orthopedic settings utilizing evidence based practicum Oversee junior team members ensuring compliance with all regulatory authorities and laws including HIPPA Successfully served as charge nurse, unit secretary, clinical preceptor and mentor to graduate / student nurses Manage employee schedules, workflow, inventory, admissions, and discharges Implement physician directed treatment plans, perform evaluations, administer medications, and chart progress Maintain working knowledge of accepted standards of care, emerging medical technology, and pharmaceuticals Fulfill duties as restraint liaison committee member for orthopedic unit Serve as patient advocate collaborating with discharge planners, medical social workers, home health agencies, and other parties to ensure a smooth transition of patients to post discharge care Instruct patients in healthy lifestyles, treatment plans, and offered emotional support as needed Provide exceptional medical team support including filing, phones, and other tasks as needed Perform all duties with positivity, professionalism, and integrity