{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"  MIEHKOAC V ","gend":0,"add":"LTSAC 6014DAOR DOOWE","city":"N CHESTERFIELD","state":"VA","zip":"23234-2738","dob":"1972-08-18","age":"","mstatus":"","insh":"40012158","cliId":"","pno":"1540897857","cno":8043257203,"email":"","ename":"","eno":"","pphy":"HOFFMAN, RICHARD","ppno":8042769305,"pcpadd":"2500 Pocoshock Pl Ste 104, ","pcpcity":"North Chesterfield","pcpstate":"VA","pcpzip":232356345,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"CENTRAL","aligned":"","ano":8043257203,"add2":"LOT C3","add3":"","madd1":"4106 CASTLEWOOD ROAD","madd2":"LOT C3","madd3":"","mcity":"N CHESTERFIELD","mstate":"VA","mzip":"23234-2738","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F20.9","F20.0","E87.1","R78.81","B95.7","N17.9","K44.9","K59.00","R05","J84.10","Z03.89","R11.10","R10.13","R11.0","R63.3","A41.9","R10.9","Z20.828","B95.8","D69.6","E11.9","E78.5","E86.1","E03.9","E87.6","Z79.1","Z79.2","A41.2","R94.31","D72.9","R11.2","Z92.89","D70.2","Z79.899","J02.9","R00.2","R41.82","E78.00","Z68.31"],"date":["2020-08-06","2021-05-15","2020-10-03","2020-10-03","2020-10-03","2020-10-03","2020-09-28","2020-09-28","2020-09-28","2020-09-28","2020-09-28","2020-09-30","2020-10-02","2020-10-02","2020-10-02","2020-09-28","2020-09-28","2020-09-28","2020-09-30","2020-09-28","2020-10-02","2020-09-28","2020-09-28","2020-09-28","2020-09-28","2020-09-28","2020-09-28","2020-09-28","2020-09-28","2020-10-02","2020-10-02","2020-10-02","2019-08-26","2019-08-26","2020-09-28","2020-10-01","2021-05-11","2019-05-01","2019-05-01"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",""]}},{"a":[]}]},{"t":"Covid Screening","q":[{"a":[]}]},{"t":"Self-Assessment and Social History","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Activities of Daily Living","q":[{"a":[]}]},{"t":"Medical History","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Family History","q":[{"a":[]}]},{"t":"Preventive Care","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Allergies \/ Medications","q":[{"a":[]},{"a":{"comment":"","sub":[["","23155010205","METFORMIN ","TAB 500MG","60","Select","Select",""],["","55111012190","ATORVASTATIN ","TAB 10MG","30","Select","Select",""],["","00703713103","HALOPER ","INJ 100MG\/ML","2","Select","Select",""],["","65862056090","PANTOPRAZOLE ","TAB 40MG","30","Select","Select",""],["","65862042005","SMZ\/TMP ","TAB 800-160","24","Select","Select",""],["","00378033401","HALOPERIDOL ","TAB 10MG","30","Select","Select",""],["","65862016001","ZOLPIDEM ","TAB 10MG","30","Select","Select",""],["","69097082607","BENZTROPINE ","TAB 0.5MG","60","Select","Select",""]]}},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Review of Systems and Diagnoses","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Pain","q":[{"a":[]}]},{"t":"Vital Signs","q":[{"a":[]},{"a":[]}]},{"t":"Exam Review","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Screenings Needed","q":[[["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""]]]},{"t":"Mini-Cog","q":[{"a":[]}]},{"t":"Home Safety & Personal Goals","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Active Problem Conditions","q":[{"a":[]}]},{"t":"Patient Summary","q":[{"a1":"","a2":"","a3":"","a4":"","a5":"","a6":"","a7":[],"a8":"","a9":"","a10":[],"a11":"","a12":""}]}]}