Stephanie Palmer

Clinical Documentation Improvement Specialist 

Christus Trinity Mother Frances of Tyler

November 2016 TO PRESENT

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Conduct concurrent documentation reviews on all selected admissions to identify principal diagnosis options, secondary diagnoses and procedures and - (A) assign a working DRG; (B) determine whether diagnoses were present on admission.

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Documentation is reassessed as patient condition / clinical results change, in order to capture accurate and thorough information. The working DRG is updated as needed. Documentation of discharge diagnosis and any co-morbidities or complications are a complete reflection of the patient's clinical status and care. Query physicians (and extenders) when record information is conflicting, ambiguous or incomplete and would affect coding and / or DRG assignment. Makes every effort to obtain responses to clarifications prior to discharge and coding of the record.

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Effectively communicate with physicians on documentation issues. In a collaborative manner, provide education feedback between physicians, Case managers and Quality. Work collaboratively with healthcare team to facilitate documentation that supports patients' severity of illness and risk of mortality. Maintains a positive working relationship with physicians and other healthcare team members, co-workers, etc.

 

 

 

 

Nurse Practice Educator 

Clairmont Longview 

August 2016 to October 2016

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The Nursing Practice Educator acts as the lead for the co-ordination and management of all educational activities in the Center. Additionally, the primary focus of the Nursing Practice Educator is to assist and support the translation of the Genesis nursing philosophy into practice by leading the planning, implementation and evaluation of education to enhance the knowledge and skills of caregivers. He or she will provide expertise in clinical nursing skills and knowledge application. The Nursing Practice Educator acts as a clinical expert for nursing staff and provides education and mentoring in the development of clinical skills and capabilities. He or she will facilitate the enhancement of nursing skills needed for care delivery involving common gerontological conditions and disease management issues. The Nursing Practice Educator assesses the clinical education needs of the staff and plans, develops, implements and evaluates educational programs to meet those needs.

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Director of Nursing 

Behavioral Hospital of Longview

September 2012 to June 2016

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September 2012 - May 2013 Psychiatric Charge Nurse- managed dual diagnosis unit, conducted nursing assessment, admissions, collaborated with physicians and clinicians to manage patient care, initiated and updated care plans, supervised floor nurse and mental health technicians.

 

May 2013- June 2016 -Director of Nursing- Supervised the care of all patients in psychiatric hospital. Managed the nursing department of approximately 120 employees which included RN's, LVN’s Mental Health Technicians, Infection Control/Employee Health Nurse, Nurse Educator, House Supervisors and Administrative Assistant/Staffing Coordinator. Played a vital role in Quality Assurance and Performance Improvement Committee, Medical Executive Committee, Utilization Review, Pharmaceutical and Therapeutics Committee, Leadership and Safety Committee and head of the Nurse Staffing Committee. Developed, revised and implemented policies and procedures to ensure compliance with governing agencies.

 

RN Case Manager

At Home Health Care

February 2009 to September 2012

 

RN Field Nurse Feb 2009 to Jan 2010 -responsible for the nursing care of the patients assigned.  Also responsible for assessing patient and family needs in order to promote the best care that the Home Health Team can give for recovery and rehabilitation.

RN Case Manager Jan 2010 to Sept 2012- Provided quality patient care via the development, implementation & evaluation of individual patient care plans. Liaison between the agency, patient, and their families.  Follows established professional standards of care, Agency guideline policy and procedures.

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Team Leader

Plaza Medical Center of Fort Worth

August 2006 To January 2009

 

Telemetry RN Floor Nurse/Charge Nurse-provided nursing care for patients with general medical issues, post cardiac cath patients, surgical and other as required for telemetry monitoring. Analyzing arrhythmias, managing medications and calculating IV drips, running ACLS codes as necessary, delegating and assigning tasks appropriately to nursing staff.

 

Team Leader- Assistant Manager to the Nurse Manager. Active in Performance Improvement Committee, Nursing Committee, and Infection Control Committee. Ensure staffing of units and coordinated schedules as needed. Performed payroll for staff as necessary. Maintains nursing staff jobs by coaching, counseling, disciplining and education as needed.

 

 

RN MICU/CCU FLOOR NURSE

Methodist Dallas Medical Center 

June 2003 to August 2006

 

Management of complex invasive hemodynamic monitoring and treatment of adult patients during the critical phase of recovery from cardiac and thoracic surgery, STEMI, and exacerbation and treatment of end stage heart failure. Management of ventilated patients, calculating and management of medication administration with IV infusions, CVVHD, IABP, cardiac monitoring, EKG, pulse oximetry, NIBP, invasive hemodynamic pressure signals, cardiac output, and advanced arrhythmia detection. Part of rapid response team for the hospital and managed ACLS codes as necessary.