Clinical Documentation Medical Records
Resume:
Charles O Lashmann
**** ******* ***** *****, ****, TX 77449. Cellphone: 832-***-****
Email: **.********@*****.***
OBJECTIVE:
A career as an Electronic Medical Records consultant with analysis and coding experience.
SKILLS:
Epic Modules – EpicCare Ambulatory, Cadence, ADT, EpicCare Inpatient, ClinDoc, CPOE, Optime, Anesthesia, ADT, ASAP, Command Center
EMR Implementation & Support
Chart control, Access and Storage
Clinical Data Analysis and Extraction
Release of information
Insurance Reimbursement/ Collections
Managed Care Regulations/ JCAHO Guidelines
Chart Status, Tracking and Assembly
HIPAA Regulations
Current HIM Technologies
ICD-9-CM and CPT coding
WORK EXPERIENCE:
August 2015 – Current - Dublin Methodist Hospital, Dublin, OH
Epic OpTime, ClinDoc, Command Center Support Pool
Assisted physicians with the following navigation skills (Manage Orders, Medication reconciliation, Note writer, Smart Phrase Manager, Result Review, Chart review, In basket, Admission, Transfer and Discharge documentation)
At the elbow support for Nurses and other clinicians
Assisted end users with clinical documentation and hyperspace navigation.
Assisted end users with completing their patient charts from the work list
May - June 2015 - Brigham Women’s Hospital, Boston, MA
Epic ClinDoc Consultant
At the elbow support for Nurses and other clinicians
Assisted end users with clinical documentation and hyperspace navigation.
Assisted end users with completing their patient charts from the work list
Assisted end users with the following navigation skills (Flow sheet, MAR, Result Review, Chart Review, Manage Orders, Admission, Transfer and Discharge documentation).
April 2015 - Montefiore Medical Center, Bronx, NY
Epic CPOE Consultant
At the elbow support for Physicians at the Physician lounge
Assisted end users with clinical documentation and hyperspace navigation
Assisted physicians with the following navigation skills (Manage Orders, Medication reconciliation, Note writer, Smart Phrase Manager, Result Review, Chart review, In basket, Admission, Transfer and Discharge documentation)
January 2015 - Bronson Battle Creek Hospital, Battle Creek, MI
Epic Optime/ADT Consultant
At the elbow support for Physicians and Nurses
Assisted end users with clinical documentation and hyperspace navigation
Assisted physicians with the following navigation skills (Manage Orders, Medication reconciliation, Note writer, Smart Phrase Manager, Result Review, Chart review, In basket, Admission, Transfer and Discharge documentation)
Assisted end users with the following navigation skills (Flow sheet, MAR, Result Review, Chart Review, Manage Orders, Event time, Status board, Unit manager).
July - October 2014 - AdvantageCare Physicians, Bronx, NY
EpicCare Ambulatory/Cadence Consultants
At the elbow support for Physicians, Nurses, Front desk at multiple specialty clinics.
Assisted front desk with the following (Creating new patient record, creating new appointments, updating patient guarantor and coverage information, patient check in and check out, cash drawer reconciliation, InBasket etc.)
Assisted nurses with the following (Patient rooming, documenting patient vitals, allergies, history and medications, documenting telephone encounters, InBasket navigation, chart review, manage orders, communication, discharge instructions etc.)
Assisted physicians with the following (Manage Orders, Medication reconciliation, Note writer, Smart Phrase Manager, Result Review, Chart review, In basket, Admission, Transfer and Discharge documentation)
June 2014 – HealthEast Care System, St Paul, MN
Epic ClinDoc/ADT Consultant
At the elbow support for Nurses and other clinicians
Assisted end users with clinical documentation and hyperspace navigation.
Assisted end users with completing their patient charts from the work list
Assisted end users with the following navigation skills (Flow sheet, MAR, Result Review, Chart Review, Manage Orders, Admission, Transfer and Discharge documentation, Unit manager).
APRIL 2014 – University of North Carolina - Chapel Hill, NC
Epic Optime/CPOE Consultant
At the elbow support for Physicians and Nurses
Assisted end users with clinical documentation and hyperspace navigation
Assisted physicians with the following (Manage Orders, order sets Medication reconciliation, Note writer, Smart Phrase Manager, Result Review, Chart review, In basket, Admission, Transfer and Discharge documentation)
Assisted end users with the following navigation skills (Flow sheet, MAR, Result Review, Chart Review, Manage Orders, Event time, Status board, Unit manager).
January 2014 - Bronson HealthCare Midwest Kalamazoo, MI
EpicCare Ambulatory/Cadence Consultant
At the elbow support for Physicians, Nurses, Front desk in specialty clinic.
Assisted front desk with the following (Creating new patient record, creating new appointments, updating patient guarantor and coverage information, patient check in and check out, cash drawer reconciliation, InBasket etc.)
Assisted nurses with the following (Patient rooming, documenting patient vitals, allergies, history and medications, documenting telephone encounters, InBasket navigation, chart review, manage orders, communication, discharge instructions etc.)
Assisted physicians with the following (Manage Orders, Medication reconciliation, Note writer, Smart Phrase Manager, Result Review, Chart review, In basket, office visit workflow, Admission, Transfer and Discharge documentation)
November – December 2013 – Wellstar Health System, Marietta, GA.
Epic ClinDoc/CPOE Consultant
At the elbow support for physicians and nurses
Assisted end users with the following navigation skills (Flow sheet, MAR, Result Review, Chart Review, Manage Orders, Admission, Transfer and Discharge documentation, Unit manager).
Assisted physicians with the following (Manage Orders, order sets Medication reconciliation, Note writer, Smart Phrase Manager, Result Review, Chart review, In basket, Admission, Transfer and Discharge documentation)
October 2013 – California Pacific Medical Center, San Francisco, CA
Epic ClinDoc/CPOE Consultant
At the elbow support for physicians and nurses
Assisted end users with the following navigation skills (Flow sheet, MAR, Result Review, Chart Review, Manage Orders, Admission, Transfer and Discharge documentation, Unit manager).
Assisted physicians with the following (Manage Orders, order sets Medication reconciliation, Note writer, Smart Phrase Manager, Result Review, Chart review, In basket, Admission, Transfer and Discharge documentation)
July – August 2013 - Mental Health & Mental Retardation Authority, Houston, TX
Health Information Technician
Select, assign and audit signatures and dates deficiency to patient medical records
Review medical documentation and consult with physicians and nurses when documentation is inaccurate/ unclear for charting
Assemble of Doctors and Nurses progress notes
Open/ Close Patients medical record charts
Thinned Patients medical charts
Retrieves and file patients medical chart
Answer phone calls requests
Release of information
Assist with all areas in the Medical Records Department
February 2012 to June 2013 – CONCIERGE REHABILITATION CENTER, Houston, TX
Certified Medication Technician
Administered morning, afternoon, evening and night medications on Weekends
Responsible for keeping accurate Narcotic medication documentation records
Assist the Nurse-in-Charge with all aspect of direct patient care
Fax re-order prescription/ Clean and refill medication-kart
Replace expired medications
CLINICAL EXPERINCES
1.05/2013 – 06/2013 - DePelchin Children’s Center, Houston, TX – 713-***-****
Medical Records Management – Preceptor; Ms. Cozettee Thomas, RHIA
2.08/2012 to 12/2012 - Michael DeBakey VA Medical Center, Houston, TX 713-***-****
Health Information Department – Preceptor; Mrs. Stephanie Hayes, RHIA
3.01/2012 to 05/2012 - IntraCare Behavioral Hospital South, Houston, TX – 713-***-****
Health Information Department – Preceptor; Mrs. Tammy Cervantes, M.S, RHIA
4.08/2011 to 12/2011- Quentin Meases Community Hospital, Houston, TX – 713-***-****
Health Information Department – Preceptor; Mrs. Jacqueline Jefferson, RHIA
EDUCATION:
01/2011 to 8/2013
HCC Coleman College for Health Sciences, Medical Center Houston, TX -
DEGREE
Associate in Applied Science in Health Information Technology
Certificates -
Health Information Analysis
Health Information Coding
RELATED COURSES:
Medical Terminology Health Information Systems Human Biology
Human Pathology Desktop Database Software Intercultural Communication Health Statistics Quality Assurance/Health Care Health Record Applications Clinical Practice Pharmacology for HIT
Health Data Classification Systems I (ICD-9-CM and CPT)
Advanced Coding and Reimbursement
Supervision and Management Practices for HIT
COMPUTER SKILLS
Microsoft Office Suite (Word, Excel, Access, Power-point and Outlook)
PERSONAL/ PROFESSIONAL REFERENCE
Available upon request.
Contact this candidate