Blake Photo Time-Line

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72010431850 Enc. Date 4/27/2020

04/27/2020 - Office Visit in O'Neal - Pediatrics

Reason for Visit Well Child

Diagnoses

Codes

Comments

Encounter for routine child health examination without abnormal findings - Primary

ICD-10-CM: Z00.129 ICD-9-CM: V20.2

Problem List as of 4/27/2020

Date Reviewed: 3/10/2020

Codes

Priority

Class

Noted - Resolved

Single liveborn infant delivered vaginally

ICD-10-CM: Z38.00 ICD-9-CM: V30.00

2/14/2020 - Present

Overview Addendum 2/14/2020 2:06 PM by Myriam Ortiz-de Jesus, MD AGA male infant , Ballard at 37 weeks. Will need car seat test.

Newborn affected by maternal use of other drugs of addiction

ICD-10-CM: P04.49 ICD-9-CM: 760.79

2/14/2020 - Present

Overview Addendum 2/14/2020 2:04 PM by Myriam Ortiz-de Jesus, MD

Polysubstance drug exposure during pregnancy. Infant UDS + for opioids. Buprenorphine screen and meconium screen pending. Infant at high risk for withdrawal and this was explained to mom as well as the need for observation for a minimum of 72 hrs. Mother verbalized understanding. Mom may breast feed infant. Plans: NAS every 3 hrs, SS consult.

Mother's group B Streptococcus colonization status unknown

ICD-10-CM: P00.2 ICD-9-CM: V29.0

2/14/2020 - Present

Overview Signed 2/14/2020 2:03 PM by Myriam Ortiz-de Jesus, MD

S/P adequate intrapartum prophylaxis.

Routine or ritual circumcision

ICD-10-CM: Z41.2 ICD-9-CM: V50.2

Unknown - Present

Patient as-of Visit

Allergies as of 4/27/2020

Allergies last reviewed by Rebecca J Houghton, LPN on 4/27/2020 1704 No Known Allergies

Immunizations as of 4/27/2020

Immunization DTaP / HiB / IPV

Administered On

04/27/2020

Hepatitis B, Pediatric/Adolescent Pneumococcal Conjugate - 13 Valent

02/14/2020, 04/27/2020

04/27/2020 04/27/2020

Rotavirus Pentavalent

Progress Notes

Progress Notes by Lois H. Gesn, MD at 4/27/2020 4:40 PM

Generated on 7/19/22 2:38 PM

Page 59