• Accurately documented real-time patient encounters under the supervision of physicians, including history of present illness, physical exams, lab and imaging results, assessments, and treatment plans in the Electronic Health Record (EHR).
• Streamlined clinical workflows by managing medical documentation, allowing providers to focus on patient care and improve overall efficiency.
• Retrieved and entered relevant patient information into EHR systems, ensuring complete and up-to-date records before, during, and after clinical visits.
• Collaborated with physicians to clarify medical terminology, procedures, and diagnoses, ensuring high-quality and compliant documentation.
• Maintained strict adherence to HIPAA regulations and patient confidentiality standards while managing sensitive health information.
• Navigated EHR systems (e.g.Athenahealth, DrChrono, MicroMD EMR) to support accurate data entry, reduce charting backlog, and meet documentation deadlines.
• Supported quality care delivery by flagging abnormal test results or documentation inconsistencies for physician review.
• Demonstrated strong knowledge of medical terminology, anatomy, pharmacology, and clinical workflows across diverse specialties (e.g., Emergency Medicine, Internal Medicine, Orthopedics).
