{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" EILLIWENAL M","gend":1,"add":"NEDRAG 0667DAOR KEERC ","city":"OAKWOOD","state":"VA","zip":"24631-8437","dob":"1961-06-08","age":"","mstatus":"","insh":"60015373","cliId":"","pno":"9467292738","cno":"","email":"","ename":"","eno":"","pphy":"MORGAN, CLAYTON L","ppno":2765966780,"pcpadd":"6719 GOVERNOR GC PEERY HWY STE 2900,","pcpcity":"Richlands","pcpstate":"VA","pcpzip":"24641-0317","pcpcounty":"","pcpid":"","pcpname":"CLINCH PROFESSIONAL PHYSICIAN SERVICES LLC","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"SOUTHWEST","aligned":"","ano":"","add2":"7660 GARDEN CREEK ROAD","add3":"","madd1":"7660 GARDEN CREEK ROAD","madd2":"","madd3":"","mcity":"OAKWOOD","mstate":"VA","mzip":"24631-8437","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E11.42","M15.8","E83.42","M54.5","R11.0","M25.522","E11.22","E11.65","N18.31","Z68.29","M79.602","E11.9","I10","M79.601","M25.512","M79.605","V49.88XA","S50.12XA","S59.912A","S59.911A","V43.52XA","Y92.410","S50.11XA","Z23","Z79.84","Z79.899","V89.2XXA","M25.531","M79.631","R73.09","R53.83","E78.5","M25.50","M25.631","R22.31","B37.3","N18.30","E78.2","Z79.4","E66.8","Z12.31","R06.02","Z87.891","E55.9","U07.1","Z86.16","E03.9","R53.81","M54.50","K57.32","K85.90","R10.9","R11.2","R19.7","R10.31","K57.90","E78.00","K76.0","E11.40","Z90.49","K85.30","E80.6","R10.11","R10.13","K56.41","R74.8","K21.9","Z86.010","Z01.810","R25.2","L53.9","K31.7","K64.0","I12.9","Z88.8","K31.89","K29.60","K64.8","H31.012","B39.9","H10.45","H16.223","H25.13","H52.221","M25.511","M25.562","M25.561","M54.2","M25.661","M25.662","M25.461","M25.462","Z51.81","J98.11","R07.9","Z68.32","M79.604","R60.0","R20.0","Z96.41"],"date":["2021-07-29","2021-07-29","2021-07-29","2021-02-02","2023-01-05","2021-03-15","2023-05-19","2022-03-24","2023-05-19","2023-01-09","2021-03-15","2022-12-29","2023-04-24","2021-04-08","2021-04-08","2023-04-24","2021-04-08","2021-04-08","2021-04-08","2021-04-08","2021-04-08","2021-04-08","2021-04-08","2021-04-08","2022-09-22","2023-04-11","2021-04-08","2021-04-15","2021-04-15","2021-10-13","2022-12-29","2023-04-24","2022-10-10","2021-04-15","2021-04-15","2021-05-05","2022-08-22","2023-05-05","2022-09-22","2021-07-29","2023-04-24","2023-01-05","2023-04-24","2022-12-29","2022-07-30","2021-11-06","2022-12-29","2022-02-11","2022-02-15","2022-04-03","2022-08-29","2023-01-05","2022-04-03","2022-04-03","2023-01-05","2022-04-03","2022-04-03","2022-05-23","2022-04-03","2022-08-22","2023-02-20","2022-05-23","2022-05-23","2022-05-23","2022-05-27","2022-10-31","2022-12-29","2022-10-31","2022-08-15","2022-08-18","2022-08-22","2022-08-22","2022-08-22","2022-08-22","2022-08-22","2022-08-22","2022-10-31","2022-08-29","2022-09-22","2022-09-22","2022-09-22","2022-09-22","2022-09-22","2022-09-22","2022-09-22","2022-10-10","2022-10-10","2022-10-10","2022-10-10","2022-10-10","2022-10-10","2022-10-10","2023-04-11","2023-01-05","2023-01-05","2023-05-19","2023-04-24","2023-04-24","2023-04-24","2023-05-19"],"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":[["","62175061743","PANTOPRAZOLE","TAB 40MG","30","Select","Select",""],["","65862042005","SMZ\/TMP DS","TAB 800-160","20","Select","Select",""],["","68001041103","GABAPENTIN","TAB 600MG","90","Select","Select",""],["","70069000510","CYANOCOBALAM","INJ 1000MCG","1","Select","Select",""],["","69452015120","VITAMIN D","CAP 50000UNT","4","Select","Select",""],["","00002771559","BASAGLAR","INJ 100UNIT","15","Select","Select",""],["","59762040105","SUCRALFATE","TAB 1GM","90","Select","Select",""],["","70010006310","METFORMIN","TAB 500MG","60","Select","Select",""],["","55111018010","TIZANIDINE","TAB 4MG","30","Select","Select",""],["","68001033508","LISINOPRIL","TAB 20MG","30","Select","Select",""],["","27808015701","ROSUVASTATIN","TAB 20MG","30","Select","Select",""],["","00023324015","REFRESH OPTI","DRO 0.5-0.9%","15","Select","Select",""],["","00597015330","JARDIANCE","TAB 25MG","90","Select","Select",""],["","45802046564","KETOCONAZOLE","SHA 0.02","120","Select","Select",""],["","57237007630","ONDANSETRON","TAB 8MG","30","Select","Select",""],["","58160082311","SHINGRIX","INJ 50\/0.5ML","1","Select","Select",""],["","59267102501","PFIZER VACC","INJ ADLT RTU","0.3","Select","Select",""],["","59746017206","PREDNISONE","TAB 5MG","5","Select","Select",""],["","68180016013","AZITHROMYCIN","TAB 250MG","6","Select","Select",""],["","64380071207","BENZONATATE","CAP 100MG","30","Select","Select",""],["","00168016330","CLOBETASOL","CRE 0.0005","30","Select","Select",""],["","57599080000","FREESTY LIBR","KIT 2 SENSOR","2","Select","Select",""],["","57599157904","FREESTYLE","TES PREC NEO","50","Select","Select",""],["","68382072216","NATEGLINIDE","TAB 120MG","60","Select","Select",""],["","00023916360","RESTASIS","EMU 0.05% OP","60","Select","Select",""],["","73070010315","INSULIN ASPA","INJ FLEXPEN","15","Select","Select",""],["","08470184001","UNFINE PNTP","MIS 32GX4MM","60","Select","Select",""],["","70461032203","FLUCLVX QUAD","INJ 2022-23","0.5","Select","Select",""],["","55111014512","FLUCONAZOLE","TAB 150MG","10","Select","Select",""],["","00169406013","VICTOZA","INJ 18MG\/3ML","9","Select","Select",""],["","59762045001","COLESTIPOL","TAB 1GM","60","Select","Select",""],["","61594000300","THERAWORX","AER RELIEF","210","Select","Select",""],["","00005200010","PREVNAR 20","INJ ","0.5","Select","Select",""],["","69367016204","PHENAZOPYRID","TAB 100MG","6","Select","Select",""],["","00904423960","MAGNESIUM","TAB 500MG","30","Select","Select",""],["","00781261305","AMOXICILLIN","CAP 500MG","56","Select","Select",""],["","00781196260","CLARITHROMYC","TAB 500MG","28","Select","Select",""],["","68001011203","LANSOPRAZOLE","CAP 30MG DR","28","Select","Select",""],["","68001050555","POLYETH GLYC","POW 3350 NF","238","Select","Select",""],["","10572010001","PEG-3350","SOL ELECTROL","4000","Select","Select",""],["","00406012305","HYDROCO\/APAP","TAB 5-325MG","6","Select","Select",""],["","52268001201","SUPREP BOWEL","SOL PREP KIT","354","Select","Select",""],["","08290320122","BD PEN NEEDL","MIS 32GX4MM","100","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":""}]}]}