{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"   ENIMSAJTREBLIG M","gend":1,"add":"            TEERTS REPMEK 1041                              ","city":"LYNCHBURG                     ","state":"VA","zip":"24501-1957","dob":"1993-12-31","age":"","mstatus":"","insh":"50015102","cliId":"","pno":"4843476449","cno":4348566798,"email":"","ename":"","eno":"","pphy":"COMBS, KIMBERLY H                                           ","ppno":"","pcpadd":"2019 Tate Springs Rd Ste A","pcpcity":"Lynchburg                     ","pcpstate":"VA","pcpzip":245011131,"pcpcounty":"","pcpid":"P9058961","pcpname":"PIEDMONT FAMILY PRACTICE","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"APT 402                                                     ","add3":"","madd1":"7500 Timberlake Rd Apt 311                                  ","madd2":"                                                            ","madd3":"","mcity":"Lynchburg                     ","mstate":"VA","mzip":"24502-2486","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","1","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F25.1","F25.0","N83.201","N83.202","R10.12","R10.9","R11.2","K58.0","K58.9","F17.210","O99.210","Z13.1","Z36.89","Z36.5","O26.899","R11.10","Z3A.00","R10.84","Z11.3","Z34.01","Z36.3","O20.0","Z53.21","R10.11","O02.1","O03.9","Z3A.01","R10.2","R51","R53.1","N92.0","R11.0","K59.00","Z71.9","O26.851","O21.9","O26.891","O46.91","W22.8XXA","J06.9","H10.31","Z34.81","O99.351","O99.341","F32.9","Z3A.11","Z87.891","G44.209","Z23","Z34.82","F31.9","J22","R68.89","L29.8","Z13.32","Z36.2","Z34.83","O47.1","O36.8130","Z3A.38","O99.343","O99.613","F12.11","F14.11","F10.11","O99.89","O36.8131","O47.9","R52","Z3A.39","Z72.89","Z3A.40","F10.21","O76","O71.4","O99.344","Z37.0","O77.0","O70.1","O80","K82.8","R93.2","Z39.2","F14.10","E87.6","E66.9","F12.10","F25.9","Z79.899","F10.20","F14.20","Q76.49","M54.5","Z20.828","M79.10","N92.6","R53.83","M47.816","R51.9","F17.200","Z68.30","F43.10","Z01.411","N83.292","D25.9","N93.9","A59.01","R07.89","R07.9","Z32.02","R35.0","R19.7","J02.9","Z20.822","G44.89","F31.4"],"date":["2021-11-03","2021-10-24","2019-03-26","2019-03-26","2019-09-18","2020-07-13","2021-01-19","2019-03-26","2020-09-11","2021-09-23","2019-04-12","2019-04-12","2020-02-20","2020-02-20","2019-04-17","2020-07-13","2020-05-24","2019-08-27","2021-05-20","2019-05-01","2020-01-17","2019-05-02","2019-05-02","2020-07-13","2019-05-12","2019-05-12","2019-10-08","2021-08-04","2019-11-04","2019-07-30","2019-08-22","2021-08-10","2019-09-18","2019-09-18","2019-10-08","2019-11-04","2019-10-07","2019-10-07","2019-10-07","2019-10-14","2019-10-14","2019-10-31","2019-11-04","2019-11-04","2020-07-13","2019-11-04","2020-05-23","2019-11-07","2020-02-20","2020-02-20","2019-12-03","2019-12-09","2021-02-19","2020-01-17","2020-01-17","2020-02-20","2020-05-20","2020-05-11","2020-05-19","2020-05-11","2020-05-11","2020-05-11","2020-05-22","2020-05-22","2020-05-11","2020-05-22","2020-05-11","2020-05-18","2020-05-18","2020-05-19","2020-05-19","2020-05-24","2020-05-22","2020-05-23","2020-05-23","2020-05-23","2020-05-24","2020-05-23","2020-05-24","2020-05-24","2020-07-13","2020-07-13","2020-07-15","2020-09-11","2020-09-11","2021-09-23","2020-09-11","2020-09-11","2021-09-23","2021-11-15","2020-09-16","2020-12-11","2021-02-05","2020-12-28","2021-09-23","2021-01-19","2021-01-19","2021-02-05","2021-09-23","2021-02-19","2021-02-19","2021-10-24","2021-04-23","2021-05-17","2021-05-17","2021-05-17","2021-05-20","2021-09-23","2021-09-23","2021-08-04","2021-08-04","2021-08-10","2021-09-23","2021-09-23","2021-09-23","2021-10-29"],"priorHcc":[null,"","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",null,"","","","","","","","","","","","","","","","","","","","","","","","","",null]}},{"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":[["","57237000805","MIRTAZAPINE","15MG","14","Select","Select",""],["","60505006501","OMEPRAZOLE","20MG","14","Select","Select",""],["","00378563259","SUMATRIPTAN","100MG","9","Select","Select",""],["","61442012710","MELOXICAM","15MG","30","Select","Select",""],["","33342006807","OLANZAPINE","5MG","30","Select","Select",""],["","16729028912","BUSPIRONE","30MG","60","Select","Select",""],["","13668001105","CITALOPRAM","40MG","30","Select","Select",""],["","70436001002","BUPROPN","150MG XL","30","Select","Select",""],["","65862049460","QUETIAPINE","300MG","30","Select","Select",""],["","75834011001","CHLORTHALID","50MG","30","Select","Select",""],["","00093031401","KETOROLAC","10MG","20","Select","Select",""],["","50111033401","METRONIDAZOL","500MG","4","Select","Select",""],["","69238153106","LARISSIA","","28","Select","Select",""],["","63402030430","LATUDA","40MG","30","Select","Select",""],["","68462010530","ONDANSETRON","4MG","20","Select","Select",""],["","00093221001","SUCRALFATE","1GM","120","Select","Select",""],["","65862085901","FAMOTIDINE","20MG","60","Select","Select",""],["","11845005651","B-1","100MG","30","Select","Select",""],["","65862042005","SMZ\/TMP","800-160","6","Select","Select",""],["","00378320525","PRAZOSIN","5MG","30","Select","Select",""],["","16571020106","DICLOFENAC","75MG DR","60","Select","Select",""],["","13668033005","TRAZODONE","50MG","30","Select","Select",""],["","59746000103","METHYLPRED","4MG","21","Select","Select",""],["","60505025203","TIZANIDINE","4MG","30","Select","Select",""],["","59779010112","PAIN","500MG","30","Select","Select",""],["","29300013901","DIVALPROEX","250MG DR","14","Select","Select",""],["","00591352530","LIDOCAINE","5%","30","Select","Select",""],["","62175061743","PANTOPRAZOLE","40MG","30","Select","Select",""],["","57237000805","MIRTAZAPINE ","TAB 15MG","14","Select","Select",""],["","60505006501","OMEPRAZOLE ","CAP 20MG","14","Select","Select",""],["","00378563259","SUMATRIPTAN ","TAB 100MG","9","Select","Select",""],["","61442012710","MELOXICAM ","TAB 15MG","30","Select","Select",""],["","33342006807","OLANZAPINE ","TAB 5MG","30","Select","Select",""],["","16729028912","BUSPIRONE ","TAB 30MG","60","Select","Select",""],["","13668001105","CITALOPRAM ","TAB 40MG","30","Select","Select",""],["","70436001002","BUPROPN ","TAB 150MG XL","30","Select","Select",""],["","65862049460","QUETIAPINE ","TAB 300MG","30","Select","Select",""],["","75834011001","CHLORTHALID ","TAB 50MG","30","Select","Select",""],["","00093031401","KETOROLAC ","TAB 10MG","20","Select","Select",""],["","50111033401","METRONIDAZOL ","TAB 500MG","4","Select","Select",""],["","69238153106","LARISSIA ","TAB ","28","Select","Select",""],["","63402030430","LATUDA ","TAB 40MG","30","Select","Select",""],["","68462010530","ONDANSETRON ","TAB 4MG","20","Select","Select",""],["","00093221001","SUCRALFATE ","TAB 1GM","120","Select","Select",""],["","65862085901","FAMOTIDINE ","TAB 20MG","60","Select","Select",""],["","11845005651","B-1 ","TAB 100MG","30","Select","Select",""],["","65862042005","SMZ\/TMP ","TAB 800-160","6","Select","Select",""],["","00378320525","PRAZOSIN ","CAP 5MG","30","Select","Select",""],["","16571020106","DICLOFENAC ","TAB 75MG DR","60","Select","Select",""],["","13668033005","TRAZODONE ","TAB 50MG","30","Select","Select",""],["","59746000103","METHYLPRED ","TAB 4MG","21","Select","Select",""],["","60505025203","TIZANIDINE ","TAB 4MG","30","Select","Select",""],["","59779010112","PAIN ","TAB 500MG","30","Select","Select",""],["","29300013901","DIVALPROEX ","TAB 250MG DR","14","Select","Select",""],["","00591352530","LIDOCAINE ","PAD 0.05","30","Select","Select",""],["","62175061743","PANTOPRAZOLE ","TAB 40MG","30","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":[[["No","Select","","","","","Select","",""],["No","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":""}]}]}