Name of the Procedure:

Documentation of medical reason(s) for prescribing or dispensing antibiotic

Common name(s): Antibiotic justification, Antibiotic prescription documentation Technical or medical terms: HCPCS Code G9712 Documentation

Summary

This procedure involves documenting the specific medical reasons or conditions for prescribing or dispensing antibiotics to a patient. It ensures that the use of antibiotics is medically justified, addressing current medical practice guidelines and reducing unnecessary antibiotic use.

Purpose

• Addresses bacterial infections and conditions requiring antibiotic treatment.
• Goals include appropriate antibiotic use, prevention of antibiotic resistance, and ensuring patient safety.

Indications

• Specific symptoms or conditions, such as:
  • Intestinal infection
  • Pertussis (whooping cough)
  • Bacterial infection
  • Lyme disease
  • Otitis media (middle ear infection)
  • Acute sinusitis
  • Acute pharyngitis (sore throat)
  • Acute tonsillitis
  • Chronic sinusitis
  • Other bacterial infections
• Patient criteria: Clinical diagnosis of a bacterial infection necessitating antibiotic treatment.

Preparation

• Ensure patient’s medical history and current symptoms are documented.
• Perform diagnostic tests or assessments to confirm bacterial infection, if necessary.
• Discuss medication history, including allergies and previous antibiotic use.

Procedure Description

• The healthcare provider documents the medical reason(s) for the antibiotic prescription in the patient's medical record.
• Utilizes electronic health records (EHR) or paper documentation systems.
• Notes may include the diagnosis, test results supporting the diagnosis, and reasons for choosing the specific antibiotic.

Duration

• Typically takes 5-10 minutes.

Setting

• Performed in various healthcare settings, including hospitals, outpatient clinics, and physician offices.

Personnel

• Primary care physicians
• Specialists (e.g., infectious disease specialists, pediatricians)
• Nurses
• Pharmacists

Risks and Complications

• Incorrect documentation could lead to inappropriate antibiotic use.
• Failure to justify the antibiotic could result in medical review and compliance issues.

Benefits

• Ensures appropriate use of antibiotics.
• Helps in combating antibiotic resistance.
• Enhances patient safety by reducing adverse drug reactions.

Recovery

• No physical recovery is needed as this is a documentation procedure.
• Follow-up may be required to monitor the patient’s response to the antibiotic therapy and adjust treatment if necessary.

Alternatives

• No direct alternatives for the documentation itself.
• Alternative treatments for the underlying condition might include:
  • Symptomatic treatment
  • Observation
  • Non-antibiotic medications depending on the diagnosis

Patient Experience

• The patient may not be directly aware of the documentation process.
• Clear communication from the healthcare provider about why an antibiotic is prescribed can ensure the patient understands the necessity and proper usage of the medication.