Usage of term, "prophylaxis"
I have a pt that presented w/ chief complaint of fever of 102.7, was treated w/ ATB both during admission and ordered post discharge. Chest xray on admission stated: Suspect pneumonia vs atelectasis.
On the DC summary, "no nidus for fever was written". A query was generated during stay, but not answered until after pt admission of why antibiotics were ordered. Query (from a query template of a well-known CDI product) was answered under heading of
"Prophylaxis, other indication: ? suspected pneumonia"
Is prophylaxis interpreted similarly to "to cover" or is prophylaxis more of a "possible" diagnosis?
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To a coder: Prophylaxis is prevention. Prevention means they don't have it. If they don't have it, you cannot report it.
AKA, you don't code DVT when a patient gets routine DVT Prophylaxis.