Audits performed on a regular basis will confirm that documentation and coding were appropriate for the level of service provided or will identify problems

The four main sections of the UB-04 claim form include all of the following EXCEPT:

patient information. billing information. physician information. diagnosis information.

You have been caring for a resident for the past several weeks who has edema of his legs and is on a sodium-restricted diet and medication to reduce the swelling. Today you count his pulse and find that it is 58 and that he reports feeling weak and apathetic. What is your response to this situation?

What will be an ideal response?