I have extensive experience with various EHR systems, including Epic and Cerner. I have worked on implementing and optimizing these systems to ensure accurate clinical documentation. My role involved training staff, troubleshooting issues, and collaborating with IT teams to enhance system functionality. I am proficient in using EHR tools to extract data for quality improvement initiatives and to ensure compliance with regulatory standards.

I ensure accuracy and completeness by conducting regular audits and providing feedback to clinicians. I also offer training sessions to educate staff on best practices for documentation. Additionally, I work closely with coding and billing departments to align documentation with coding requirements, ensuring that the information captured supports accurate reimbursement and reflects the patient's clinical status.

I implement strategies such as regular feedback loops, targeted education, and the use of clinical documentation improvement (CDI) software. I also focus on identifying and addressing common documentation gaps through root cause analysis. By fostering a culture of continuous improvement, I ensure that clinicians are aware of the importance of accurate documentation and are equipped with the tools and knowledge to achieve it.

I approach conflicts by maintaining open communication and focusing on the shared goal of improving patient care. I listen to clinicians' concerns, provide evidence-based explanations for best practices, and work collaboratively to find solutions. By fostering a respectful and supportive environment, I aim to build trust and ensure that any disagreements are resolved constructively.

In a previous role, I identified a recurring issue where clinicians were not documenting patient allergies accurately. This led to potential medication errors. I conducted a thorough review, identified the root cause, and developed a training program to address the issue. Following the training, I monitored the documentation and saw a significant improvement in accuracy. This experience reinforced the importance of proactive monitoring and education in maintaining high-quality documentation.