Clinical Documentation Specialist Resume

Records or data are crucial for not only other organizations, but healthcare entities too. The details may be of patients' vital sings, treatment offered, lab reports, surgeries recommended and done, etc. These documents help the medical industry in avoiding legal complications, meeting regulatory, and serving insurance needs of patients, as well as for future references. To document the records, healthcare facilities employ clinical documentation specialists. These specialists may also be someone who has served as a registered nurse or an LPN for several years.

Since medical documents can help doctors and the healthcare facility at the time of malpractice charges, employers required experienced, honest, and hard-working people to handle responsibilities of this position. Therefore, when creating a clinical documentation specialist resume, ensure that your experience speaks volume about your capabilities for the job.

Clinical Documentation Specialist Resume Example

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David E. Hayes
104 School Street
New Haven, CT 06510
Phone: 203-781-5807
Email: dehayes@freemail.com

Career Objective:

To obtain a clinical documentation specialist position in 'Prime Care Hospital' and apply my experience and skills in reviewing patients' medical records and creating clinical documents for insurance, legal and reference purpose.

Summary of Skills:

• Licensed registered nurse with four years of experience in documenting clinical records
• Knowledge of the state, federal, and local regulations implied on health care industry
• Excellent computer and communication skills
• Skilled in drafting clinical reports and presentations
• Ability to maintain confidentiality of patients' information
• Strong interpersonal and team-building skills
• Excellent manual dexterity with multitasking ability
• Physically fit to carry 30 lbs, walk and stand for hours

Work Experience:

Clinical Documentation Specialist
Christ Memorial Hospital, New Haven, CT
March 2012 Present

• Document clinical details of patients' conditions, diagnoses, and progress
• Ensure all relevant information pertaining of patient care is documented
• Document CAT scans, EKGS, and blood sample results
• Assist patients in submitting form for insurance
• Participate in inter-departmental training
• Review medical records and attest supporting documents
• Answer queries of patients and medical staff
• Gather, compile, and modify clinical documentation

Clinical Documentation Specialist
Central Health Care Center, New Haven, CT
June 2010 - February 2012

• Ensured all medical records of the center is complete and accurate
• Interacted with physicians and assigned ICD-9 CM codes
• Evaluated documentation and communicated with physicians
• Helped in improved documentation systems through research
• Worked closely with nurses for documenting clinical information
• Applying codes to medical records

Education:

• Bachelor's Degree in Nursing
  Angel's Medical College, New Haven, CT
  2007

• Associate Degree in Health Information Management
  Angel's Medical College, New Haven, CT
  2009

References:

On request.