Bacteremia
ICD-10 R78.81 is a billable code used to indicate a diagnosis of bacteremia.
Bacteremia refers to the presence of bacteria in the bloodstream, which can lead to serious infections and systemic inflammatory responses. It is often a sign of an underlying infection that may not be localized, such as pneumonia, urinary tract infections, or skin infections. Symptoms may include fever, chills, tachycardia, and hypotension, which can progress to septic shock if not promptly treated. Laboratory findings typically include positive blood cultures, which confirm the presence of bacteria. The clinical context of bacteremia is critical, as it can indicate severe illness and requires immediate medical intervention. The condition can arise from various sources, including surgical procedures, intravenous drug use, or infections that breach the body's barriers. Accurate diagnosis and timely treatment are essential to prevent complications such as sepsis or organ failure.
Detailed documentation of patient history, clinical findings, and laboratory results is essential. The source of bacteremia should be identified when possible.
Patients presenting with fever and chills, suspected infections, or those with chronic illnesses requiring hospitalization.
Consider the patient's overall clinical picture, including comorbidities and potential sources of infection.
Acute care documentation must include vital signs, initial assessment findings, and any interventions performed.
Patients presenting with septic shock, altered mental status, or severe infections requiring immediate intervention.
Rapid assessment and documentation are crucial, as timely treatment can significantly impact patient outcomes.
Used when blood cultures are performed to confirm bacteremia.
Document the reason for the culture and the clinical findings leading to the test.
Ensure that the culture results are linked to the diagnosis of bacteremia.
Bacteremia refers specifically to the presence of bacteria in the bloodstream, while sepsis is a systemic inflammatory response to infection that can occur as a result of bacteremia.
