<p>General Summary:</p> <p>Document physician dictated patient history, physical examination, family, social, and past medical history as well as document procedures, lab results, and any other information pertaining to the patient's office visit.</p> <p>Principal Duties & Responsibilities:</p> <p>Example of Essential Duties:</p> <ul> <li>Accompany physician into the patient examination room in order to transcribe a history and physical exam, and document accurately the physician's encounter with the patient and others present </li><li>Documents accurately quality measure information in the patient chart </li><li>Accurately lists all assessed diagnoses and relevant symptoms or treatment plans including follow up instructions and prescriptions as dictated by the physician </li><li>Transcribe patient orders including laboratory tests, radiology tests, medications, etc. </li><li>Document any procedures performed by the physician </li><li>Chart Prep </li><li>Follows best practices for documentation </li><li>Assist with other general clerical and clinical work within the office </li><li>Other duties as assigned </li></ul> <p>Knowledge, Skills & Abilities Required:</p> <p>Required:</p> <ul> <li>Excellent communication and organizational skills required. </li><li>Recognition of physical exam process and ability to record exam details. </li><li>Excellent typing skills </li><li>Knowledge of Medical Terminology </li><li>Computer proficiency and ability to quickly learn new applications </li><li>Consistently arrives at work, in professional attire, on time and completes all tasks within established time frame. </li><li>Seeks appropriate tasks when primary tasks are completed and assists co-workers as needed. </li><li>Demonstrates adaptability to expanded roles. </li><li>Adheres to all clinic policies and procedures. </li></ul> <p>Education:</p> <p>Required: High school diploma or equivalent.</p> <p>Medical Terminology courses strongly preferred.</p> <p>Preferred:</p> <p>6 months of previous experience as a Scribe.</p>