{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"  LALIDAVLETAP K ","gend":0,"add":"IHC 5492LP NOTL","city":"VIRGINIA BEACH","state":"VA","zip":"23456-9998","dob":"1942-08-03","age":"","mstatus":"","insh":"04000910*101","cliId":"5GX3R83HY86","pno":"75\/7572290-5","cno":"757\/575-0922","email":"","ename":"","eno":"","pphy":"PATEL, JITENDRA MD","ppno":"757\/471-3100","pcpadd":"2020S INDEPENDENCE SUITE 1","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23456,"pcpcounty":"","pcpid":101215,"pcpname":"Family and Internal Medical Center","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M17.12","M17.11","E10.65","Z79.4","Z79.899","E10.9","E11.9","E78.2","D64.9","E03.9","D47.3","E11.65","K44.9","M17.5","C02.9","J92.9","Z23.","Z92.29","E78.5","E55.9"],"date":["2020-10-15","2020-10-15","2021-08-25","2021-01-10","2020-09-17","2021-01-10","2021-01-11","2021-11-23","2021-11-23","2021-01-11","2021-11-23","2021-11-23","2021-11-23","2021-11-23","2021-11-23","2021-11-23","2021-02-27","2021-11-23","2021-11-23","2021-11-23"],"priorHcc":["","",null,"","","","",null,null,"",null,null,null,null,null,null,"",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":[["","2771559","BASAGLAR","INJ 100UNIT","15","Select","Select",""],["","2822259","INSULIN LISP","INJ 100\/ML","15","Select","Select",""],["","193731150","CONTOUR","TES NEXT","300","Select","Select",""],["","2803101","GLUCAGON","KIT 1MG","-1","Select","Select",""],["","59267100001","PFIZER VACC","INJ COVID-19","0","Select","Select",""],["","8290320122","BD PEN NEEDL","MIS 32GX4MM","300","Select","Select",""],["","8290326895","BD SWAB REG","PAD SNGL USE","300","Select","Select",""],["","81131006044","ALCOHOL SWAB","PAD ","-300","Select","Select",""],["","49281012065","FLUZONE HD","INJ PF 20-21","1","Select","Select",""],["","70010075405","METHOCARBAM","TAB 500MG","45","Select","Select",""],["","65702071110","ACCU-CHEK","TES GUIDE","400","Select","Select",""],["","169643810","LEVEMIR","INJ FLEXTOUC","30","Select","Select",""],["","2771559","BASAGLAR KWIKPEN","","15","Select","Select",""],["","193731221","CONTOUR NEXT BLOOD GLUCOSE TEST ","","400","Select","Select",""],["","8290320122","BD PEN NEEDLE\/NANO\/ULTRA -FINE\/32G X 4MM","","300","Select","Select",""],["","70010075405","METHOCARBAMOL ","","-45","Select","Select",""],["","49281012065","FLUZONE HIGH-DOSE PF 2020-2021","","1","Select","Select",""],["","81131006044","RELION ALCOHOL SWABS ","","300","Select","Select",""],["","2822259","INSULIN LISPRO KWIKPEN","","15","Select","Select",""],["","8290326895","BD SWABS SINGLE USE","","300","Select","Select",""],["","2803101","GLUCAGON EMERGENCY KIT","","-1","Select","Select",""],["","65702071110","ACCU-CHEK GUIDE ","","400","Select","Select",""],["","169643810","LEVEMIR FLEXTOUCH","","30","Select","Select",""],["","59267100001","PFIZER-BIONTECH COVID-19 VACCINE","","0","Select","Select",""],["","81131006044","RELION ALCOHOL SWABS","","-300","Select","Select",""],["","00193731221","CONTOUR NEXT BLOOD GLUCOSE TEST","","400","Select","Select",""],["","70010075405","METHOCARBAMOL","","-45","Select","Select",""],["","65702071110","ACCU-CHEK GUIDE","","400","Select","Select",""],["","49281012065","FLUZONE HIGH-DOSE PF 2020-2021                                        ","INJ PF 20-21","1","Select","Select",""],["","08290326895","BD SWABS SINGLE USE                                                   ","PAD SNGL USE","300","Select","Select",""],["","00193731221","CONTOUR NEXT BLOOD GLUCOSE TEST                                       ","TES NEXT","400","Select","Select",""],["","00002822259","INSULIN LISPRO KWIKPEN                                                ","INJ 100\/ML","15","Select","Select",""],["","70010075401","METHOCARBAMOL                                                         ","TAB 500MG","45","Select","Select",""],["","00002771559","BASAGLAR KWIKPEN                                                      ","INJ 100UNIT","3","Select","Select",""],["","08290320122","BD PEN NEEDLE\/NANO\/ULTRA -FINE\/32G X 4MM                              ","MIS 32GX4MM","300","Select","Select",""],["","81131006044","RELION ALCOHOL SWABS                                                  ","PAD ","-300","Select","Select",""],["","00169643810","LEVEMIR FLEXTOUCH                                                     ","INJ FLEXTOUC","30","Select","Select",""],["","00002803101","GLUCAGON EMERGENCY KIT                                                ","KIT 1MG","1","Select","Select",""],["","65702071110","ACCU-CHEK GUIDE                                                       ","TES GUIDE","400","Select","Select",""],["","59267100001","PFIZER-BIONTECH COVID-19 VACCINE                                      ","INJ COVID-19","0","Select","Select",""],["","00006483703","PNEUMOVAX 23                                                          ","INJ 25\/0.5","0","Select","Select",""],["","08290320550","BD PEN NEEDLE\/NANO 2ND GEN\/32G X 5\/32\"                                ","MIS 32GX5\/32","300","Select","Select",""],["","49281012165","FLUZONE HIGH-DOSE PF 2021-2022                                        ","INJ 2021-22","1","Select","Select",""],["","00088221905","LANTUS SOLOSTAR                                                       ","INJ 100\/ML","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":[[["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["N\/A","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":""}]}]}