MH

MARJORIE HENSLEY

REGISTERED NURSE CLINICAL DOUMENTATION IMPROVEMENT

OBJECTIVE

Clinical Documentation Improvement Specialist with 26 years of experience in a variety of fields such as renal, urology, transplantation, neurology and ICU/CCU. I have over 9 years of experience in Clinical Documentation. Always a team player and willing to help a fellow colleague in need. I appreciate constructive criticism to improve performance.

SKILLS

Critical thinking proficiency

Effective communication

Medical record documentation evaluations

Ability to use multiple software platforms

Team player

Actively participates in Quality Initiative program

Ability to change and grow

EXPERIENCE

NORTH CAROLINA STATE VETERANS HOME RN/QAPI/FALLS COORDINATOR- 4/19/23-PRESENT.

UTILIZE VARIOUS REPORTING TOOLS TO DISCOVER TRENDS/PATTERNS.

EDUCATIONAL OFFERINGS TO STAFF RELATED TO FALLS.

FALLS AUDITING.

PART OF ADMINISTRATION TEAM WITH ON CALL FOR 4 HOURS ON WEEKEND. CONDUCT DETAILED REPORT OF ANY REPAIRS/FIXES THAT NEED TO DONE IN OR AROUND FACILITY.

UPDATE ADMINISTRATION ABOUT NEW PIP’S(PERFORMANCE IMPROVEMENT PROJECTS)

CONDUCT BED AUDITS.

SOUTHWEST MEDICAL CENTER-RN/CDIS COORDINATOR-7/22-PRESENT

Uncovered discrepancies in the health records and contact physicians to provide further documentation to clarify these issues.

Effectively utilized the query process to obtain quality and integrity for the medical record.

Interact with physicians daily to educate and clarify deficiencies in the medical record.

Used various reports within Chartwise for the use in quarterly bonuses for hospitalists.

Attend daily IDT rounds where we discuss length of stay, patient condition and any barriers at discharge.

Attending weekly HARMS/HAC meeting to go over both in- house and discharged patients. We discuss any HAC/Harm that has been identified and follow up as needed, whether that is a conversation with a physician or a query.

Ongoing educational offerings.

CAPE FEAR VALLEY HEALTH SYSTEM • RN/CDIS•FROM 9/17-7/22

Uncovered discrepancies in the health records and contact physicians to provide further documentation to clarify these issues.

Effectively utilized the query process to obtain quality and integrity for the medical record.

Interact with physicians daily to educate and clarify deficiencies in the medical record.

Actively maintain up to date knowledge of applicable changes in regulations both state and federal to follow query process. I attend weekly webinars on a variety of topics.

Mortality chart reviews as well as long length of stay patients. Responsible for finding any undocumented CC’s or MCC’s to raise SOI/ROM to reflect severity of condition.

Ability to work on a variety of platforms to ensure the most appropriate documentation for the patient’s record.

Appropriately capture necessary documentation to allow more clarity for claims.

Work with other CDIS in the department to resolve questions and issues.

Observe strict confidentiality to include all patient related information.

Transitioned from Cerner/Sorian product to Epic.

Coding the patient’s chart concurrently. Coder input begins at the time of discharge. I continue to work unresolved queries after discharge. I work with HIM/Coding to correct any mismatches, Quality issues, and implementation of retro queries when appropriate.

LOGAN REGIONAL MEDICAL CENTER Clinical Documentation Specialist 1/13-8/17

Uncovered discrepancies in the health records and contacted physicians to provide further documentation to clarify these issues.

Effectively utilized the query process to obtain quality and integrity to the medical record.

Interact with physicians daily to educate and clarify deficiencies in the medical record.

Actively maintain up to date knowledge of applicable changes in regulations both state and federal to follow query process. I attend weekly webinars every week on a variety of diagnosis.

Ability to work on a variety of platforms to ensure the most appropriate documentation for the patient’s record.

Appropriately capture necessary documentation to allow more clarity for claims.

Work with other CDIS in the department to resolve questions and issues.

Observe strict confidentiality to include all patient related information.

One of 2 CDIS to begin the program implementation successfully. Ability to effectively use Meditech, Huron, Chart Wise, ChartMaxx, 3M and Meditech.

Responsible for initial and ongoing education for physicians, nurses, and case management.

Responsible to attend daily rounds to address outliers and update any DRG changes that have occurred, as well as general length of stay for that DRG and current length of stay.

Responsible for attending monthly and quarterly medical staff meetings to provide statistics and any changes to the process in the facility and updated information on coding changes.

Began monthly CDI Newsletter to distribute to reinforce education. Also began physician recognition for different kinds of challenges such increase in appropriate responses, decrease in unknown or unable to determine responses etc.

Monitored metrics for CDIS such as reviews per day, response rates, and query rates. Implemented solutions to address any issues.

Planned activities and education specials during CDIS week.

Learned how to shift the focus of physicians from a monetary standpoint to a complete record view.

Responsible for dealing with physicians with different tactics to encourage open communication lines.

WOODHAM & ASSOCIATES • PRN CLINICAL DOCUMENTATION AUDITOR (REMOTE) • Tequesta, FL 11/14-4/15

Learned the process of working remotely with frequent phone calls and emails to ensure proper follow-up and to decrease delays.

Ability to work well independently with minimal supervision.

Ability to use web-based applications for maintaining accurate time for payroll.

Ability to multi-task and use a variety of different systems, based on assignment of facility.

Ability to critique other clinical documentation specialist’s records and give appropriate recommendations.

Extensive utilization of Excel spreadsheets to expedite the vital information back to leadership.

LOGAN REGIONAL MEDICAL CENTER Case Management 9/12-1/13

Responsibilities included assuring patients had a safe home environment to go back to. Find appropriate rehabilitation services or nursing home placement as needed. Interact with physicians daily to obtain all services and equipment needed to prevent readmissions and increase good patient outcomes.

Reported to CPS/APS as needed.

Coordinated with multi-agencies for discharge planning. Appropriately capture necessary documentation to allow for needed services.

Attended rounds every day to report on status of all patients in house.

LOGAN REGIONAL MEDICAL ICU Director/Manager 6/06 -9/09

Performed essential duties over critical care area including budgeting, staffing, hiring, terminations, and staff education for 12 bed unit.

Served on many committees such as Rapid Response Team, Stroke Protocols, and Standardizing DVT prophylaxis. Also attended Medical Staff meetings for medical and surgical to present education, issues with process and questions as needed. Attended rounds every day to report on status of all patients in house.

Established and implemented departmental policies, goals, objectives with interaction with physicians, nursing, and corporate officers.

2011-2013 Charleston Area Medical Center-RN Neurology

Cared for patients with CVA, Dementia, Alzheimer’s, Guillain-Barré Syndrome, Glioblastomas, Seizures etc.

Also worked in Progressive Care caring for acutely ill, Telemetry, post-operative burr holes, craniotomies, etc. And Neuro ICU with critical patients with drains, burr holes, halos.

1995-2011 Charleston Area Medical Center-RN Renal, urology and transplantation. RN

Responsible for pre-op transplant recipients testing and reinforcement of education.

Responsible for transplant patient’s daily lab results and

weights. Responsible for drawing labs for central line and shipping to lab.

Starting peritoneal dialysis with or without additives. Education of patient about clean technique, diet, etc. Utilized CCPD machine or traditional in and out bags. Obtaining weight and dry weights.

Charge nurses most nights either with or without orientees with full load patients

Attended staffing rounds where we planned for any further

admissions, moving patients to receive any new renal, urology or transplantation from ED or other floors.

Ability to stick arteriovenous grafts in emergency situations.

EDUCATION

ADN •1995 • SOUTHERN WEST VIRGINIA AND TECHNICHAL COLLEGE

Hold unencumbered multi-compact state RN license. Previously Certified Peritoneal Dialysis Nurse, Previous BLS and ACLS.

VOLUNTEER EXPERIENCE OR LEADERSHIP

Volunteer for many hospital and community events such as Free Health Fairs and yearly sports physicals for youths. Drive-Thru-Flu Shots to increase the number of vaccinations to prevent avoidable sickness and deaths. Participated in yearly education booths for entire facility. Took donations for a local State Park so that they could increase their ability to maintain and potentially add new displays for Christmas in the Park.

Was ICU/CCU director for 3 years and learned an extensive amount of information regarding revenue cycle, budgeting, staffing and the ability to communicate effectively. As well as managing people, inventory, policies and procedures and the ability to maintain the department so that it was conducive to the patient and family’s wellbeing with appropriate information and treatments. Maintain a balance of work life for staff to prevent burnout and mistakes.

Instituted policy and procedure for Rapid Response program and implementation. Had multi-disciplinary input with Radiology, Pharmacy, Respiratory Therapy, Lab, ED, Physician and Leadership. Many hours of research and development based on our patient population and disease processes.

REFERENCES- PROFESSIONAL

Dan Bray RN/CCDS Manager

Fayetteville NC

ad1436@r.postjobfree.com

Valerie Newsome RN, BSN, CCDS

183 Right Fork Laurel Creek

Lenore, WV 25676

304-***-****

Jillian Hubbard MPH, RN, ACM-RN, CCDS

Jacksonville, Florida

904-***-****

EMAIL: ad1436@r.postjobfree.com

304-***-**** -CELL

910-***-****-HOME

Address

1085 Strickland Bridge Road

Fayetteville, NC 28304

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