Tara Lacey

Pre Anesthesia Assessment Nurse

• Extensive review of patients medical history.
• Review of patient medications and what to be administered pre-procedure
• Phone triage interview with patient 2/3 weeks prior to procedure for phone assessment and patient education.
• Medical assessment for appropriate pre operative testing that would need completed.
• Ordering of pre operative testing per guidelines
• Review of testing and lab results
• Information on patients reviewed sent to Anesthesia.
• Pre operative assessment sent to Short Stay Unit in preparation for procedure
• 24 and 72 hour review of patients to assess any changes in medical condition.

• Categorized health services and assigned specific diagnosis code to each one.
• Maintained current working knowledge of CPT and ICD-10 coding principles, government regulation, protocols and third-party billing requirements.
• Read through patient health data, histories, physician diagnoses and treatments to gain understanding for coding purposes.
• Reviewed account information to confirm patient and insurance information is accurate and complete.
• Actively maintained current working knowledge of CPT and ICD-9 coding principles, government regulation, protocols and third party requirements regarding billing.
• Assigned additional diagnosis codes based on specific clinical findings (laboratory, radiology and pathology reports as well as clinical studies) in support of existing diagnoses.
• Communicated with healthcare personnel, including practitioners to promote accuracy.
• Reconciled clinical notes, patient forms and health information for compliance with HIPAA rules.
• Quickly responded to staff and client inquiries regarding CPT codes.
• Interpreted medical terminology and pharmacological information to translate information into coding system.
• Acted as liaison between business department, billers and third party payers in resolving billing and reimbursement accuracy.
• Maintained positive working relationship with fellow staff and management.
• Answered questions and fulfilled requests with friendly and knowledgeable service.
• Pulled patient records and transferred information to appropriate parties.
• Safeguarded medical records to maintain patient confidentiality.
• Entered patient insurance, demographic and health information into software and confirmed records.
• Proofread documents carefully to check accuracy and completeness of all paperwork.
• Released information to persons or agencies according to regulations.
• Located and retrieved files, assisting public with general information.
• Mentored junior team members and managed employee relationships.
• Assessed patient needs, prioritized treatment, maintained patient flows and assisted physicians with non-invasive procedures.
• Administered medications and treatments, monitoring patients for reactions and side effects.
• Adhered to infection control procedures to facilitate safe, clean patient environment.
• Evaluated patients, recognized and addressed complications and coordinated treatment with other members of critical care team.
• Maintained thorough, accurate and confidential documentation in electronic medical records.
• Acted as patient advocate and implemented total patient care through team nursing process.
• Recorded patient condition, vital signs, recovery progress and medication side effects.
• Monitored and managed various treatment and care interventions.
• Advocated for patients by supporting and respecting basic rights, values and beliefs.
• Administered medications, tracked dosages and documented patient conditions.
• Trained and mentored new RNs on best practices, hospital policies and standards of care.
• Updated charts throughout shifts with current, accurate information to maintain strict recordkeeping standards.
• Provided patient and family health education focusing on self-management, prevention and wellness.
• Assessed and prepared patients for procedures, performing initial and ongoing patient assessments.

• Assessed patient needs, prioritized treatment, maintained patient flows and assisted physicians with non-invasive procedures.
• Administered medications and treatments, monitoring patients for reactions and side effects.
• Adhered to infection control procedures to facilitate safe, clean patient environment.