Blake Photo Time-Line

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

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

Acct #: 72010283868 Enc. Date 3/10/2020

03/10/2020 - Office Visit in O'Neal - Pediatrics

Reason for Visit Well Child

NICU

Diagnoses

Codes

Comments

Well child check, newborn 8-28 days old - Primary

ICD-10-CM: Z00.111 ICD-9-CM: V20.32

Problem List as of 3/10/2020

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 3/10/2020

Allergies last reviewed by Lois H. Gesn, MD on 3/10/2020 1139 No Known Allergies

Immunizations as of 3/10/2020 Immunization

Administered On

Hepatitis B, Pediatric/Adolescent

02/14/2020

Progress Notes

Progress Notes by Lois H. Gesn, MD at 3/10/2020 11:00 AM Author: Lois H. Gesn, MD Service: —

Author Type: Physician

Filed: 3/10/2020 11:46 AM

Encounter Date: 3/10/2020

Creation Time: 3/10/2020 11:39 AM

Status: Signed

Editor: Lois H. Gesn, MD (Physician)

Generated on 7/19/22 2:38 PM

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