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Heather Williams

@heatherwilliams2

Registered Nurse at Union Hospital who reviews cardiovascular records and communicates clinically significant findings across care teams.

United States

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What I'm looking for

I'm seeking to apply my acute-care nursing experience and documentation review skills to inpatient Clinical Documentation Integrity, supporting accurate representation of severity of illness, services provided, and the clinical record.

At Union Hospital, I review patient histories, diagnoses, diagnostic results, orders, medications, procedural plans, and perioperative records to understand each patient's clinical picture. I assess high-acuity cardiovascular patients and communicate significant findings and care concerns to surgeons, anesthesia providers, and the wider team.

As a Remote Telephone Triage Registered Nurse at Dial-A-Nurse / Ascension St. Vincent, I assessed patients using their histories, symptoms, records, and clinical protocols to determine urgency and disposition. I identified urgent findings and information gaps, communicated concerns, and documented assessments and outcomes in electronic systems.

My nursing experience also includes emergency, trauma ICU, and PACU settings, where I reviewed diagnostic findings and treatment responses and maintained accurate clinical records. I'm prepared to apply this acute-care experience to inpatient Clinical Documentation Integrity; I have not held a formal CDI specialist role.

Experience

Work history, roles, and key accomplishments

Current

CVOR / Cardiovascular Circulating Registered Nurse

Current

Union Hospital

Jun 2023 - Present (3 years 4 months)

Review patient histories, diagnoses, diagnostic results, orders, medications, procedural plans, and perioperative records to support a complete understanding of each patient’s clinical picture. Assess high-acuity cardiovascular patients and communicate clinically significant findings to surgeons, anesthesia providers, and multidisciplinary team members.

Clinical Assessment Electronic Documentation Epic Cerner Meditech Salesforce Microsoft Word Excel Outlook HIPAA compliance Quality Assurance Regulatory Compliance

Remote Telephone Triage Registered Nurse

Dial-A-Nurse / Ascension St. Vincent

Nov 2021 - May 2023 (1 year 6 months)

Performed remote clinical assessments using patient histories, symptoms, available medical records, and clinical protocols to determine urgency and appropriate disposition. Reviewed clinical information to identify urgent findings, incomplete information, potential gaps in care, and situations requiring provider clarification or escalation.

Telephone Triage Clinical Assessment Electronic Documentation Salesforce EMR Communication Skills Referral Coordination Confidentiality

PACU / Medical-Surgical Registered Nurse

CHI St. Joseph

Jul 2021 - Nov 2021 (4 months)

Assessed post-anesthesia and medical-surgical patients, reviewed orders, diagnostic findings, medication information, and responses to treatment. Collaborated with physicians, anesthesia, nursing, and other care team members to communicate patient status and support safe transitions.

Post Anesthesia Care Medical Surgical Nursing Clinical Assessment Electronic Documentation Collaboration Handover Communication

Emergency Department Travel Registered Nurse

Multiple facilities in KY, WV & VA

May 2019 - Apr 2021 (1 year 11 months)

Completed rapid assessments and reviewed clinical histories, diagnostic results, medications, treatment responses, and supporting documentation for patients with acute and emergent conditions. Worked closely with physicians and interdisciplinary teams on diagnostic workups, treatment plans, admissions, transfers, and disposition decisions.

Emergency Nursing Rapid Assessment Clinical Documentation Interdisciplinary Collaboration Triage Prioritization

Trauma ICU Registered Nurse

University of Kentucky

May 2020 - Jul 2020 (2 months)

Cared for critically ill trauma patients requiring continuous assessment, complex interventions, and coordinated multidisciplinary management. Monitored trends in laboratory results, diagnostic findings, hemodynamic status, and response to treatment; escalated significant changes to appropriate providers.

Trauma Nursing Critical Care Hemodynamic Monitoring Clinical Documentation Multidisciplinary Collaboration Escalation Management

Emergency Department Registered Nurse

KentuckyOne Health

Performed comprehensive assessments for patients with diverse acute and emergent conditions, using clinical judgment to identify severity, prioritize care, and support appropriate disposition. Reviewed clinical documentation, diagnostic findings, medication histories, and treatment responses and communicated relevant information to physicians and care teams.

Emergency Nursing Clinical Assessment Triage Clinical Documentation Communication Skills CEN Daisy Award