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Documentation of order for first or second generation cephalosporin for antimicrobial prophylaxis

HCPCS code

Name of the Procedure:

Documentation of Order for First or Second Generation Cephalosporin for Antimicrobial Prophylaxis (G9197)


This procedure involves the documentation of a healthcare provider’s order for the use of first or second-generation cephalosporins, a type of antibiotic, to prevent infections during surgical procedures.


The primary goal is to prevent surgical site infections by administering antibiotics before, during, or shortly after surgery. This helps reduce the risk of postoperative infections, leading to improved patient outcomes and a reduction in hospital stay duration.


  • Patients undergoing surgical procedures with a high risk of infection.
  • Individuals with a history of recurrent infections or compromised immune systems.
  • Surgeries involving implantation of prosthetic devices.


  • Patients are advised to inform their healthcare provider of any allergies, especially to antibiotics.
  • Fasting might be required if the prophylaxis is part of a surgical procedure.
  • Preoperative assessments, such as blood tests or allergy testing, might be conducted.

Procedure Description

  1. A healthcare provider assesses the need for antimicrobial prophylaxis.
  2. The provider documents the order for first or second-generation cephalosporin.
  3. The appropriate antibiotic is selected based on patient history and surgical type.
  4. The antibiotic is typically administered intravenously before the surgical incision and may be continued postoperatively.

    Equipment Used: Intravenous cannula, antibiotic solution, sterile syringes.

    Anesthesia: Not applicable directly for the administration of antibiotics; depends on the surgical procedure.


The documentation process takes a few minutes, while the antibiotic infusion usually lasts 30 minutes to an hour.


The procedure typically takes place in a hospital setting, including operating rooms or preoperative areas.


  • Surgeons
  • Anesthesiologists
  • Nurses
  • Pharmacists

Risks and Complications

  • Allergic reactions to cephalosporins, ranging from mild rashes to severe anaphylaxis.
  • Antibiotic resistance if used inappropriately.
  • Gastrointestinal disturbances like nausea or diarrhea.


  • Significant reduction in postoperative infection rates.
  • Faster recovery and shorter hospital stays.
  • Decreased need for additional surgeries related to infections.


As this is a preventive measure, there is no specific recovery related to the antibiotic administration itself. Patients should monitor for any allergic reactions and report them immediately.


  • Use of other classes of antibiotics if cephalosporins are contraindicated.
  • Non-antibiotic measures, such as aseptic surgical techniques and postoperative wound care.

    Pros and Cons: While other antibiotics may be used, cephalosporins are typically chosen for their effectiveness and broad spectrum. Non-antibiotic measures are essential but may not be sufficient alone for high-risk surgeries.

Patient Experience

  • Patients may feel a slight discomfort from the IV insertion.
  • Rare cases of mild allergic reactions, which will be managed by the healthcare team.
  • Pain management and comfort measures will be provided as part of the overall surgical care plan.

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