{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" EILUJHSAC M","gend":1,"add":"OT 947DR YAK","city":"NEWPORT NEWS","state":"VA","zip":"23601-2639","dob":"1965-02-08","age":"","mstatus":"","insh":"21010109","cliId":"","pno":"0975772513","cno":"","email":"","ename":"","eno":"","pphy":"FESSEHAIE TEKLE MD","ppno":7576796058,"pcpadd":"12388 WARWICK BLVD STE 302,","pcpcity":"Newport News","pcpstate":"VA","pcpzip":"23606-3858","pcpcounty":"","pcpid":"","pcpname":"DOMINION PATIENT CARE SERVICES","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"TIDEWATER","aligned":"","ano":"","add2":"749 TOKAY RD","add3":"","madd1":"749 TOKAY RD","madd2":"","madd3":"","mcity":"NEWPORT NEWS","mstate":"VA","mzip":"23601-2639","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R68.81","R11.2","R63.4","G43.719","R52","F17.210","Z63.72","F11.14","F43.21","F41.9","F32.9","Z23","M25.512","M62.838","R10.11","M54.5","G89.29","J40","I10","E09.610","K52.9","R79.89","E27.8","R10.13","R11.11","R11.10","R94.5","E27.9","M54.9","K21.9","J44.9","Z87.442","Z79.899","R10.9","K76.9","N28.9","K63.89","D72.829","R10.84","H53.8","F32.A","F51.5","N94.10","F43.10","K85.20","N39.0","M79.7","K86.0","F11.10","E86.0","R00.0","Z53.29","K85.90","D25.9","F10.10","F19.10","R80.9","I49.1","K86.81","R19.7","Z20.822","G47.00","K86.89","M79.672","H91.90","H53.9","M25.531","F33.9","Z78.0","Z90.721","F43.11","M19.031","H90.3","H61.21","H93.13","Z77.122","Z82.2","N94.2","Z03.818","B34.9","R05.9","R09.81","K25.9","D64.9","I49.8","K29.80","K29.70","K27.9","E83.42","K86.1","R10.10","K31.89","K26.9","Z72.0","K31.5","M19.90","G40.909","F17.209","K29.60","R93.3","K44.9","Z79.01","K31.9","K26.3","F41.8","R07.82","S20.211A","W19.XXXA","Z87.11","Z87.19","N63.24","B35.4","J44.0","Z13.89","M19.041","M65.321","M65.4","Z01.810","I51.7","Z88.5","J44.1","Z86.16","F41.0","F17.200","G43.009","K29.50","F19.90","I11.9","Z59.6","A06.2","M25.641","Z53.21","G58.8","E87.6","M79.10","F43.12","R53.82"],"date":["2021-01-08","2023-03-16","2021-01-08","2023-05-25","2023-05-25","2023-05-25","2023-05-25","2022-10-17","2021-03-02","2023-03-16","2022-09-08","2021-05-03","2021-04-05","2021-04-05","2022-12-06","2021-05-03","2022-04-18","2021-05-04","2023-05-25","2021-05-04","2022-12-06","2021-06-11","2022-12-06","2022-12-06","2021-06-11","2021-06-11","2021-06-11","2022-12-06","2021-06-11","2023-03-16","2022-12-06","2022-12-06","2022-09-08","2023-01-14","2021-06-30","2021-06-11","2022-12-06","2021-06-30","2022-03-23","2021-11-22","2022-03-25","2021-12-29","2021-11-22","2022-09-08","2022-05-04","2021-12-18","2022-09-08","2022-03-23","2021-12-29","2021-12-18","2022-08-15","2021-12-18","2022-04-29","2021-12-18","2022-10-17","2022-01-01","2021-12-20","2022-12-06","2022-03-22","2022-04-04","2022-03-23","2021-12-29","2021-12-29","2023-05-25","2022-03-23","2022-01-07","2022-01-07","2022-02-25","2022-01-07","2022-01-07","2022-01-07","2022-01-07","2022-01-21","2022-01-21","2022-01-21","2022-01-21","2022-01-21","2022-01-24","2022-02-13","2022-02-14","2023-03-16","2022-02-14","2022-03-23","2022-02-23","2022-02-23","2022-03-22","2022-03-23","2022-04-29","2022-03-25","2022-03-22","2023-01-14","2022-04-29","2023-03-16","2022-03-25","2022-03-28","2022-09-08","2022-03-23","2022-03-28","2022-03-23","2022-03-23","2022-03-23","2022-03-23","2022-03-24","2022-03-29","2022-03-28","2022-04-17","2022-04-17","2022-04-17","2023-01-14","2022-12-06","2023-05-25","2023-05-25","2023-05-25","2023-05-25","2023-01-19","2023-01-06","2022-09-08","2022-08-15","2022-08-15","2022-09-08","2022-09-26","2022-09-26","2022-10-17","2022-10-17","2023-05-12","2022-10-17","2022-10-17","2022-12-06","2022-12-06","2023-01-03","2023-01-06","2023-01-14","2023-01-19","2023-05-12","2023-05-12","2023-05-12","2023-05-12"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",""]}}]},{"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":[]},{"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":[]}]},{"t":"Allergies \/ Medications","q":[{"a":[]},{"a":{"comment":"","sub":[["","27241009903","DULOXETINE","CAP 60MG","30","Select","Select",""],["","68180072003","AMLODIPINE","TAB 5MG","60","Select","Select",""],["","67877024801","QUETIAPINE","TAB 400MG","30","Select","Select",""],["","00115180401","HYDROXYZ PAM","CAP 50MG","90","Select","Select",""],["","16571020150","DICLOFENAC","TAB 75MG DR","60","Select","Select",""],["","00591336905","BUT\/APAP\/CAF","TAB ","30","Select","Select",""],["","57664016758","METOPROL TAR","TAB 100MG","60","Select","Select",""],["","43598050930","ESOMEPRA MAG","CAP 20MG DR","30","Select","Select",""],["","12496120803","SUBOXONE","MIS 8-2MG","60","Select","Select",""],["","00173069600","ADVAIR DISKU","AER 250\/50","60","Select","Select",""],["","68462015713","ONDANSETRON","TAB 4MG ODT","20","Select","Select",""],["","68462019005","NAPROXEN","TAB 500MG","60","Select","Select",""],["","69315012710","FOLIC ACID","TAB 1000MCG","30","Select","Select",""],["","10006070011","VITAMIN B1","TAB 100MG","30","Select","Select",""],["","68382005105","MELOXICAM","TAB 15MG","30","Select","Select",""],["","52817033200","CYCLOBENZAPR","TAB 10MG","60","Select","Select",""],["","00093406901","PRAZOSIN HCL","CAP 5MG","30","Select","Select",""],["","68382004101","PROMETHAZINE","TAB 25MG","30","Select","Select",""],["","00591352530","LIDOCAINE","PAD 0.05","30","Select","Select",""],["","55111064530","OMEPRAZOLE","CAP 40MG","30","Select","Select",""],["","00093321915","KETOCONAZOLE","CRE 0.02","15","Select","Select",""],["","00597007541","SPIRIVA","CAP HANDIHLR","30","Select","Select",""],["","00173068220","VENTOLIN HFA","AER","18","Select","Select",""],["","00186037220","SYMBICORT","AER 80-4.5","10.2","Select","Select",""],["","00143122701","DICYCLOMINE","TAB 20MG","84","Select","Select",""],["","00093216568","NALOXONE HCL","SPR 4MG","2","Select","Select",""],["","31722099601","HYDROCO\/APAP","TAB 5-325MG","10","Select","Select",""],["","13668021630","ARIPIPRAZOLE","TAB 2MG","30","Select","Select",""],["","69452014430","BENZONATATE","CAP 200MG","30","Select","Select",""],["","00904515460","GUAIFENESIN","TAB 200MG","30","Select","Select",""],["","00093083205","CLONAZEPAM","TAB 0.5MG","60","Select","Select",""],["","00093005301","BUSPIRONE","TAB 5MG","90","Select","Select",""],["","65862056099","PANTOPRAZOLE","TAB 40MG","60","Select","Select",""],["","49884094499","VARENICLINE","TAB 0.5& 1MG","53","Select","Select",""],["","49035030882","PAIN RELIEVR","TAB 500MG","30","Select","Select",""],["","66689030516","SUCRALFATE","SUS 1GM\/10ML","1200","Select","Select",""],["","42858000101","OXYCODONE","TAB 5MG","30","Select","Select",""],["","11877001140","BINAXNOW COV","KIT HOME TES","2","Select","Select",""],["","63304082805","ATORVASTATIN","TAB 20MG","30","Select","Select",""],["","50111078710","AZITHROMYCIN","TAB 250MG","6","Select","Select",""],["","59746017509","PREDNISONE","TAB 20MG","10","Select","Select",""],["","69543038810","KETOROLAC","TAB 10MG","20","Select","Select",""]]}},{"a":[]},{"a":[]},{"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":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Pain","q":[{"a":[]}]},{"t":"Vital Signs","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Exam Review","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Screenings Needed","q":[{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":[]}]},{"t":"Mini-Cog","q":[{"a":[]},{"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":"","a13":""}]}]}