Patient Care Medical Records
Resume:
LH
LILLIE HUNT
************@*****.******* 760-***-**** Mansfield, TX 76063
Medical records computer charting
Catheter placement
Cpr_ bls certified
Assessment and charting
Vital signs, blood sugar
Diabetes management
Compassionate Care
Tracheostomy Care
Vital signs monitoring
Clinical Documentation
Catheter Care
Elderly Care
Wound Care
Family Communication
Physical Assessment
Patient Intake
Behavioral assessment
Empathetic and compassionate
Caring for wounds
Geriatric Care
Educating families
Patient Management
Patient Care
Medication Dispensing
Direct Patient Care
ADL Assistance
Patient triaging
Multi-tasking and prioritization
Pennsylvania rehab nursing Fort Worth,
Texas
LVN Charge Nurse
09/2016 - 04/2020
Performed patient assessments, developed individualized care plans, and monitored progress.
Coordinated with other members of the healthcare team to ensure proper implementation of treatment plans for patients.
Maintained accurate medical records and documentation of patient visits. Monitored vital signs, recorded observations, and reported changes to physicians or nurses in charge.
Assessed patients' physical condition through observation, interviews, tests, and review of medical histories.
Conducted rounds to evaluate the quality of nursing care being provided. Adhered to infection control standards while handling specimens or performing any clinical duties.
Responded promptly to emergency situations such as cardiac arrests or life-threatening events.
Assigned tasks appropriately based on each staff member's abilities. Charted changes in patient conditions and discussed concerns with supervising healthcare provider.
Addressed patient care needs, collected vitals, dressed wounds and managed catheters.
Administered medications in accordance with policies and legal limitations.
Observed and reported changes in condition of patients and signs and Summary
Skills
Experience
symptoms of deviations from normal health status.
Documented adverse patient reactions to medications and reported findings to supervisors.
Administered medications and therapies in accordance with physicians orders.
Took temperatures or blood pressures, dressed wounds and provided other basic patient care or treatments.
Measured and recorded patient height, weight and other vital signs. Observed strict confidentiality and safeguarded all patient-related information.
Guaranteed exceptional care quality by correctly administering medication, inserting and caring for catheters, dressing and changing wounds and assisting with personal hygiene.
Communicated with patients with compassion while keeping medical information private.
Collected blood, urine or sputum from patients to perform routine laboratory tests.
Communicated effectively with patients and loved ones to explain diagnoses, treatment options and procedures.
Answered patients' calls to determine how to assist. Provided behavioral and emotional support and closely supervised patients suffering from dementia and Alzheimer's.
Delivered high-quality direct and indirect nursing care to patients. Monitored infection control procedures to verify facility-wide health and safety.
Assembled and used catheters, tracheotomy tubes or oxygen suppliers. Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
Prepared or examined food trays for conformance to prescribed diet. Provided direct patient care by taking vital signs, administering medications and treatments, and providing wound care. Assisted in the admission, discharge and transfer of patients. Maintained accurate medical records for each patient utilizing electronic health record systems.
Conducted physical assessments of patients on a regular basis. Responded quickly to life threatening situations using appropriate interventions based on established protocols.
Ordered lab tests or imaging studies according to physician orders while ensuring accuracy of documentation in the medical record system. Evaluated effectiveness of treatments by observing responses from patients during therapy sessions or after medication administration periods have elapsed.
Identified potential problems that could impact the quality of care delivered to patients including issues related to staffing or equipment shortages and deficiencies.
Collected and documented vital signs to track current patient conditions. Monitored patient's respiration activity, blood pressure and blood glucose levels in response to medical administration.
Communicated concerns regarding patients' status, care and environment to nursing supervisors, clinical care supervisors and case managers. Answered patient and family questions to educate on optimal treatment procedures.
Interviewed patients to obtain medical history.
Promoted culture of safety for patients and employees through proper identification, reporting documentation and prevention. Used sterile techniques to prepare patients for procedures. Followed rehabilitation and treatment care plans to accelerate patient recovery, minimize pain, and optimize patient outcomes. Applied interventions to progress patients toward wellness and address maintenance of wellness.
Prevented drug interactions and contributed to correct diagnosis by recording patient health information, monitoring vitals and updating patient files.
Collected biological specimens and packaged for laboratory transport to complete diagnostic tests.
Documented patient medical histories, current symptoms and vitals. Prepared patients for examinations, tests or treatments and explained procedures.
Collected biological samples for routine laboratory testing to assist diagnostic processes.
Ensured compliance with all safety regulations and policies within the facility.
Answered patient calls, identified issues and determined how best to provide assistance within parameters established by facility and supervisor.
Legends Fort Worth, Texas
Lvn
09/2018 - 02/2020
Assisted in the admission, discharge and transfer of patients. Provided direct patient care by taking vital signs, administering medications and treatments, and providing wound care. Conducted physical assessments of patients on a regular basis. Ensured compliance with all state laws governing nursing practice standards.
Responded quickly to life threatening situations using appropriate interventions based on established protocols.
Ordered lab tests or imaging studies according to physician orders while ensuring accuracy of documentation in the medical record system. Evaluated effectiveness of treatments by observing responses from patients during therapy sessions or after medication administration periods have elapsed.
Actively participated in continuing education activities in order to stay abreast of latest developments in nursing practices, procedures, techniques
.
Educated patients and families on health maintenance and disease prevention.
Looked for physical, emotional, and symptomatic changes in patient condition and obtained necessary care for medical concerns. Collected and documented vital signs to track current patient conditions. Monitored patient's respiration activity, blood pressure and blood glucose levels in response to medical administration.
Interviewed patients to obtain medical history.
Used sterile techniques to prepare patients for procedures. Applied interventions to progress patients toward wellness and address maintenance of wellness.
Prevented drug interactions and contributed to correct diagnosis by recording patient health information, monitoring vitals and updating patient files.
Collected biological specimens and packaged for laboratory transport to complete diagnostic tests.
Managed patient records, ensuring confidentiality and compliance with healthcare regulations.
Administered medications and therapies in accordance with physicians orders.
Charted changes in patient conditions and discussed concerns with supervising healthcare provider.
Addressed patient care needs, collected vitals, dressed wounds and managed catheters.
Took temperatures or blood pressures, dressed wounds and provided other basic patient care or treatments.
Documented patient medical histories, current symptoms and vitals. Measured and recorded patient height, weight and other vital signs. Answered patient calls, identified issues and determined how best to provide assistance within parameters established by facility and supervisor.
Observed strict confidentiality and safeguarded all patient-related information.
Guaranteed exceptional care quality by correctly administering medication, inserting and caring for catheters, dressing and changing wounds and assisting with personal hygiene.
Communicated with patients with compassion while keeping medical information private.
Answered patients' calls to determine how to assist. Provided behavioral and emotional support and closely supervised patients suffering from dementia and Alzheimer's.
Delivered high-quality direct and indirect nursing care to patients. Monitored infection control procedures to verify facility-wide health and safety.
Evaluated nursing intervention outcomes by conferring with other healthcare team members.
Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
Prepared or examined food trays for conformance to prescribed diet. Remarkable Healthcare and Rehabilitation
Center Fort Worth, Texas
LVN
10/2018 - 10/2019
Assisted in the admission, discharge and transfer of patients. Provided direct patient care by taking vital signs, administering medications and treatments, and providing wound care. Performed routine diagnostic tests such as EKG's, urinalysis and blood draws.
Monitored vital signs, including temperature, pulse, respiration rate, and blood pressure.
Administered medications as prescribed by physician orders. Responded promptly to patient call lights and requests for assistance. Performed routine treatments such as dressing changes and wound care. Maintained accurate documentation of patient assessment data, interventions performed and responses to treatments per facility policy. Assisted with transferring patients from beds to strhers or wheelchairs using proper body mechanics techniques.
Ensured that all equipment was properly maintained according to established standards of practice.
Demonstrated knowledge of infection control policies and procedures when providing patient care services.
Utilized critical thinking skills while dealing with complex clinical situations.
Adhered to safety regulations regarding hazardous materials and waste disposal.
Managed time effectively while multitasking in high-pressure situations. Developed positive relationships with co-workers through effective communication.
Supervised CNAs and other staff delivering care in setting by coaching and supporting.
Completed required forms and chart documentation of vital signs, medications and other information.
Collected and documented vital signs to track current patient conditions. Monitored patient's respiration activity, blood pressure and blood glucose levels in response to medical administration.
Promoted culture of safety for patients and employees through proper identification, reporting documentation and prevention. Used sterile techniques to prepare patients for procedures. Followed rehabilitation and treatment care plans to accelerate patient recovery, minimize pain, and optimize patient outcomes. Prevented drug interactions and contributed to correct diagnosis by recording patient health information, monitoring vitals and updating patient files.
Collected biological specimens and packaged for laboratory transport to complete diagnostic tests.
Administered medications and therapies in accordance with physicians orders.
Charted changes in patient conditions and discussed concerns with supervising healthcare provider.
Addressed patient care needs, collected vitals, dressed wounds and managed catheters.
Took temperatures or blood pressures, dressed wounds and provided other basic patient care or treatments.
Measured and recorded patient height, weight and other vital signs. Answered patient calls, identified issues and determined how best to provide assistance within parameters established by facility and supervisor.
Answered patients' calls to determine how to assist. Delivered high-quality direct and indirect nursing care to patients. Monitored infection control procedures to verify facility-wide health and safety.
Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
Comfort Care Home Health LLC Dallas,
Texas
LVN
07/2016 - 09/2017
Provided direct patient care by taking vital signs, administering medications and treatments, and providing wound care. Monitored patient progress, reported changes to physician and provided education to families regarding medical conditions. Assessed patient needs for additional services such as social work or home health aides.
Conducted physical assessments of patients on a regular basis. Ensured compliance with all state laws governing nursing practice standards.
Provided emotional support to patients and their families during difficult times.
Educated patients about preventative measures for healthy living such as exercise routines, dietary guidelines and smoking cessation programs. Actively participated in continuing education activities in order to stay abreast of latest developments in nursing practices, procedures, techniques
.
Assisted with end-of-life decisions by providing compassionate support for both patients and their families during this challenging time period. Looked for physical, emotional, and symptomatic changes in patient condition and obtained necessary care for medical concerns. Collected and documented vital signs to track current patient conditions. Monitored patient's respiration activity, blood pressure and blood glucose levels in response to medical administration.
Promoted culture of safety for patients and employees through proper identification, reporting documentation and prevention. Used sterile techniques to prepare patients for procedures. Facilitated communication between patients, families, and healthcare professionals.
Administered medications and therapies in accordance with physicians orders.
Charted changes in patient conditions and discussed concerns with supervising healthcare provider.
Addressed patient care needs, collected vitals, dressed wounds and managed catheters.
Took temperatures or blood pressures, dressed wounds and provided other basic patient care or treatments.
Documented patient medical histories, current symptoms and vitals. Observed strict confidentiality and safeguarded all patient-related information.
Communicated with patients with compassion while keeping medical information private.
Delivered high-quality direct and indirect nursing care to patients. Monitored infection control procedures to verify facility-wide health and safety.
Evaluated nursing intervention outcomes by conferring with other healthcare team members.
Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
Counseled clients, patients and families and provided emotional and psychosocial support.
Heritage Home Healthcare Fort Worth,
Texas
LVN
09/2014 - 09/2016
Provided direct patient care by taking vital signs, administering medications and treatments, and providing wound care. Monitored patient progress, reported changes to physician and provided education to families regarding medical conditions. Maintained accurate medical records for each patient utilizing electronic health record systems.
Assessed patient needs for additional services such as social work or home health aides.
Conducted physical assessments of patients on a regular basis. Instructed patients on proper self-care techniques such as medication administration, nutrition management and disease prevention strategies. Ensured compliance with all state laws governing nursing practice standards.
Responded quickly to life threatening situations using appropriate interventions based on established protocols.
Participated in team meetings to discuss patient progress and plan treatment goals accordingly.
Educated patients about preventative measures for healthy living such as exercise routines, dietary guidelines and smoking cessation programs. Evaluated effectiveness of treatments by observing responses from patients during therapy sessions or after medication administration periods have elapsed.
Identified potential problems that could impact the quality of care delivered to patients including issues related to staffing or equipment shortages and deficiencies.
Actively participated in continuing education activities in order to stay abreast of latest developments in nursing practices, procedures, techniques
.
Served as an advocate for individualized patient care by coordinating resources within facility limits while promoting cost effective solutions whenever possible.
Educated patients and families on health maintenance and disease prevention.
Participated in interdisciplinary team meetings to discuss patient care. Looked for physical, emotional, and symptomatic changes in patient condition and obtained necessary care for medical concerns. Collected and documented vital signs to track current patient conditions. Communicated concerns regarding patients' status, care and environment to nursing supervisors, clinical care supervisors and case managers. Answered patient and family questions to educate on optimal treatment procedures.
Used sterile techniques to prepare patients for procedures. Collected biological specimens and packaged for laboratory transport to complete diagnostic tests.
Participated in quality improvement initiatives to enhance patient care outcomes.
Facilitated communication between patients, families, and healthcare professionals.
Managed patient records, ensuring confidentiality and compliance with healthcare regulations.
Addressed patient care needs, collected vitals, dressed wounds and managed catheters.
Took temperatures or blood pressures, dressed wounds and provided other basic patient care or treatments.
Measured and recorded patient height, weight and other vital signs. Observed strict confidentiality and safeguarded all patient-related information.
Communicated with patients with compassion while keeping medical information private.
Worked with social workers, physical therapists and speech therapists to assess patient needs, plan and adjust plans of care and actualize nursing interventions to promote and restore patient health. Collected blood, urine or sputum from patients to perform routine laboratory tests.
Communicated effectively with patients and loved ones to explain diagnoses, treatment options and procedures.
Provided behavioral and emotional support and closely supervised patients suffering from dementia and Alzheimer's.
Monitored infection control procedures to verify facility-wide health and safety.
Educated clients, patients and caregivers on medical diagnoses, treatment options, chronic disease self-management and wound management. Evaluated nursing intervention outcomes by conferring with other healthcare team members.
Collaborated with multi-disciplinary staff to improve overall patient care and response times.
San Diego Christian College Santee, CA
Bachelor of Arts in Human Development And Family Studies 05/2002
Joliet School of Practical Nursing Joliet
License Practical Nursing in Nursing
08/1970
Education and Training
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