At a senior care and home health practice, I documented patient encounters, medical histories, assessments, treatment plans, and provider recommendations in EMR systems. I prepared SOAP notes covering HPI, ROS, assessment, and plan.
I prepared and updated patient charts before appointments, checking clinical documentation for completeness, accuracy, and consistency. I also retrieved and organized medical records and coordinated document requests.
I tracked laboratory and diagnostic imaging orders and results, following up on missing reports and outstanding documentation. I maintained patient census records and spreadsheets while supporting referrals, prescription refills, and clinical administrative workflows in accordance with HIPAA requirements.
