Bandana Rai
33 Howarth Street, Ropes Crossing,NSW
Summary
Motivated Clinical Documentation Specialist for over one and half years with extensive nursing background and sound clinical knowledge and organizational skills honed over 10-year nursing career in acute and critical care settings. Highly passionate individual who can work well autonomously or collaboratively. Diligent and reliable clinical documentation specialist focused on completing tasks efficiently with consistent outstanding results under fast paced constantly changing environment. Experienced with clinical documentation, ensuring accurate and compliant medical records. Utilizes critical thinking and attention to detail to enhance patient care and support healthcare teams. Track record of collaboration and adaptability in dynamic environments. A collaborative team player and effective problem solver who is respectful, a quick learner, approachable, resilient and highly adaptable individual who values both individual and organizational goals with proficient written and verbal communication skills. Self-driven to achieve targeted goals within or prior deadlines executing eminent quality of work.
Overview
15
15
years of professional experience
Work History
Clinical Documentation Specialist (CDS)
WSLHD, Blacktown Hospital
02.2023 - Current
- Review records of inpatient hospital admission of discharged as well as concurrent episodes to identify gaps in clinical documentation
- Provide education by conducting presentations to the clinicians- doctors, nurses, allied health professionals etc
- Raising verbal and eMR queries to clarify ambiguous, inadequate documentation or possible missed diagnoses
- Continuously participating in clinician engagement for achieving organisational goals
- Auditing and maintenance of various spreadsheets
- Ensure meeting daily KPIs (key performance indicators) for substantial impact
- Working autonomously and in team as per job task demands
- Preparing and presenting powerpoint presentations to participate in CDS capacity building meetings
- Liaising with clinicians, coders, managers and stakeholders via MS teams, online meetings, face-to-face meetings to achieve targeted goals
- Use of PT tool to identify if a condition requires queries from clinicians to accurately capture the diagnoses
- Working onsite as well as remotely/work from home as per WSLHD guidelines and criteria
- Support new fellow CDS and perform peer audits with feedback
- Work close with JMOs of own specialties organising, planning and discussing documentation related issues as well as various levels of senior clinicians
- Participating in meetings via MS teams/face-to-face, documenting meeting minutes, preparing presentations and capturing all diagnoses with accuracy to reflect true clinical picture
Clinical Documentation Specialist
Westmead Hospital
10.2022 - 01.2023
- Review records of inpatients episode of cares and identify any gaps in clinical documentation
- Provide support to junior medical officers (JMOs) and own specialties on clinical documentation
- Auditing and providing feedback on non-compliance points
- Raising eMR queries, forwarding coders’ queries to relevant medical officers
- Liaise with JMOs, advanced trainees, consultants, head of departments to clarify queries or any ambiguity in documentation
- Maintaining own spreadsheet as a record and entering data onto MS teams
- Organise education sessions to JMOs, provide feedback and ad hoc education during own specialties paper rounds
- Use of PT audit tools for reviews and audits allocated to each CDS accordingly
- Work in collaboration with fellow CDS, managers, educators, clinical coders, HIRS department staff and clinicians in line with organisation’s CORE values
Registered Nurse- E3C, Intensive Care Services (ICS)
Westmead Hospital
01.2020 - 01.2023
- Caring for critically ill patients with wide varieties of health conditions relating to but not limited to medical/surgical, emergency, cardiothoracic, trauma, respiratory, hepato-biliary, obstetrics, gynaecology, vascular, upper GI, toxicology, renal, neurology, orthopaedics, plastics, ophthalmology, maxillo-facial, etc
- Accurately recording and following treatment plans on patients’ vitals, diagnosis, symptoms, management as per ICU team into electronic record system
- Caring for patients on inotropes and vasopressors to support their haemodynamic stability
- Looking after intubated patients under different modes of ventilation: Synchronized Intermittent Mandatory ventilation with pressure regulated volume control and pressure support known as SIMV(PRVC)PS, Pressure support ventilation, Volume control, pressure control mode, Continuous positive airway pressure (CPAP) or pressure support (PS) mode and making adjustments in consultation with ICU team to promote stabilization
- Set up and monitor medical equipment and devices like cardiac telemetry, mechanical ventilator alarms, oxygen delivery devices such as high flow nasal prongs, CPAP, arterial line set up and transducers or pressure lines
- Collect specimens for laboratory tests- blood, urine, faeces, sputum, wound swabs, drains
- Perform pulmonary assessments to identify abnormal breathing sounds by auscultating, palpating, monitoring chest status and interpreting chest x-rays
- Arterial blood gas (ABG) sampling and interpreting ABGs to monitor patient’s conditions and seeking medical advice accordingly
- Set up and management of intra-abdominal pressures (IAP)
- Assist physicians with procedures like insertion of arterial lines, central lines, bronchoscopy, endotracheal intubation, transthoracic/transoesophageal echocardiogram, chest drain insertions
- Collecting sputum sample by attending non-bronchoscopic broncho alveolar lavage in patients with airborne precaution
- Management of critically unwell patients with extra-ventricular drains (EVD)
- Maintain quality care and support patients and families during end-of-life care decisions whilst paying respect to their cultural diversities and beliefs
- Prioritize nursing cares for assigned critically unwell patients according to the assessment data and identify needs and escalation to optimize treatment
- Participate in development and continuing education to improve practice knowledge skills
- Admitting and discharge planning as appropriate by liaising with multidisciplinary team
- Administer medications through various routes-oral, intravenous, nasogastric, orogastric, intravenous, intramuscular, subcutaneous accurately as ordered by physicians
- Prepare rooms for admissions by stocking and checking all emergency equipment, setting up suction, ventilators, sharps bin and necessary items
- Train and guide student nurses, junior fellow nurses in proper techniques, care standards, operational procedure, and safety protocols in line with ICU policies to deliver outstanding care for critically ill patients
- Provide support and offer services for families and patients during unexpected end-of-life situations with empathy and compassion
- Preceptor role to new staff to facilitate their clinical learning experience in critical care environment
Registered Nurse- A3C, Surgical High Dependency Unit
Westmead Hospital
02.2012 - 01.2020
- Provide outstanding care to all patients admitted in the unit
- Admission, preparation for pre-operative patients and post-operative cares with close haemodynamic monitoring with cardiac telemetry
- Taking electrocardiogram (ECG), document hourly observations, assess wounds and identify need for escalation of any deterioration in patient condition to ward medical officer and treating medical team and/or other multidisciplinary team with A to G assessment and findings using ISBAR tool for communication
- Complex and simple wounds management E.g
- Vac dressing changes, open wound dressings, prevena plus dressings, superficial to deep tissue injuries dressing changes
- Various drains management
- E.g
- Penrose, blake, bellovac, yates, corrugated drains, Redon drains, etc
- Stoma cares-bag changes, output management, stoma site cares and educating patient and families for long-term stoma cares
- Percutaneous endoscopy gastrostomy (PEG) tube/percutaneous endoscopic jejunostomy (PEJ) tube care, management and educating patients and families on feeds management via PEG/PEJ tubes
- Tracheostomy care, plastics flaps and grafts management
- Stump cares
- Leech therapy (using leeches)/ chemical leeching (heparin-soaked gauzes) to affected areas to promote circulation
- Pain management-patient controlled analgesia, epidural, ketamine infusions, peripheral nerve infusions
- Total parenteral nutrition
- Chest drain management, removals
- Nasogastric tube insertion, indwelling catheter insertion and removals
- Continuous bladder irrigation
- Continuous ambulatory peritoneal dialysis (CAPD)
- Bloods and blood products with safe handling
- Cytotoxic oral/IV medication administration and wastes management
- Central venous access device/ peripherally inserted central venous catheters dressing/line changes, removal and management
- Venepuncture for venous blood collection and peripheral intravenous cannulation
- Initiating clinical emergencies such as rapid response/code blues by early identification of patient deterioration
- Patient advocacy between medical team and patient or/and families
- Work efficiently as a team leader of the shift managing patient flow, staff and supplies
- Seeking advice and escalate concerns to senior authorities like nurse unit manager, after hours manager, clinical nurse consultants in order to establish safe work environment and management
- Be responsible for own profession development by actively participating in education sessions, attending mandatory trainings and going for seminars/conferences to boost clinical knowledge and skills
- Identify potential hazards/risks at work and notify concerned departments and acting promptly
- Organise inter/intra hospital discharges/transfers and community referrals to continue patient care
- Adhere to ward and hospital policies on infection control, occupational health and safety whilst maintaining code of ethics
- Accurate documentation in electronic records and entering incident information management system (IIMS) where applicable to raise concerns
- Be a resource person to fellow workers, nursing students, junior nurses and support them with clinical knowledge, critical thinking and nursing skills
- Participate in ward meetings, volunteer to conduct in services to consolidate own knowledge and engage in ward activities to continuously promote nursing practice and management
- Be preceptor to new graduate nurses by supporting them and teaching them ward care standards, protocols, care plans and policies
- NSQHS Standard 7: Bloods and Blood Products Auditor, A3C, Westmead Hospital
New Graduate Registered Nurse
Prince of Wales Private Hospital
02.2011 - 01.2012
- Three Rotations in 12 months period: Ward 6 North (Orthopaedics/neurosurgery), Ward 6 South (General surgical-colorectal, gynaecology, upper GI, urology), Ward 5 East (Cardiology, cardiothoracic, vascular, ENT)
Assistant in Nursing
Royal North Shore Hospital
07.2009 - 10.2010
Education
Graduate Certificate in Critical Care - Critical Care Nursing
University of Tasmania
01-2014
Bachelor of Nursing -
Australian Catholic University
01-2010
Diploma of Accounting -
Central College
01-2007
Skills
- Excellent interpersonal communication skills (both verbal and written) and ability to work within diverse team efficiently
- Strong organizational skills and prioritizing skills with effective time management
- Proficient in computer skills- EMR, IPM applications, ERIC, MS word, power point, windows XP, excel
- Strong work ethic
- Leadership skills and delegation skills
- Self-prompter and task focused
- Great presentation skills
- A brilliant Team player as well as Individual player
- Documentation compliance
- Process improvements
- Proficient in eMR, powerchart, ERIC, iPM
Timeline
Clinical Documentation Specialist (CDS)
WSLHD, Blacktown Hospital
02.2023 - Current
Clinical Documentation Specialist
Westmead Hospital
10.2022 - 01.2023
Registered Nurse- E3C, Intensive Care Services (ICS)
Westmead Hospital
01.2020 - 01.2023
Registered Nurse- A3C, Surgical High Dependency Unit
Westmead Hospital
02.2012 - 01.2020
New Graduate Registered Nurse
Prince of Wales Private Hospital
02.2011 - 01.2012
Assistant in Nursing
Royal North Shore Hospital
07.2009 - 10.2010
Graduate Certificate in Critical Care - Critical Care Nursing
University of Tasmania
Bachelor of Nursing -
Australian Catholic University
Diploma of Accounting -
Central College
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