You are . . . managing the front desk when a new patient, Diana Pike arrives. A chest x-ray performed in the office showed an infiltrate in the right lower lobe of the lung. Diana has been complaining of pain in her right side, which is stabbing in nature. She needs to be referred to the hospital for further assessment and treatment. In your post, be sure to refer to the information and resources presented in your activities and readings for this unit.

From the position of an insurance auditor, what data is missing or weak? How could he/she interpret, or misinterpret, the note? How might this impact Diana's referral?

What consequences might this bring to your practice and its practitioners?

How would you approach the physician in order to update the note? Who's help might you enlist? Please be sure to support your posts with supporting details, providing sources or links as needed.