{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"W   DIVADNOSPMOHT ","gend":0,"add":" SEMAJ 4499DAOR REVIR","city":"SHIPMAN","state":"VA","zip":"22971-9998","dob":"1970-10-13","age":"","mstatus":"","insh":"04000910*786","cliId":"","pno":"99\/4342706-6","cno":"","email":"","ename":"","eno":"","pphy":"FQHC-MEDICAL CENTER, BLUE RIDGE FQHC","ppno":"434\/263-5953","pcpadd":"4038 THOMAS NELSON HWY","pcpcity":"ARRINGTON","pcpstate":"VA","pcpzip":22922,"pcpcounty":"","pcpid":"","pcpname":"BLUE RIDGE HEALTH CENTER INC","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","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":["D50.9","Z13.6","R73.9","F31.32","F51.01","F90.0","K91.2","K28.9","E66.9","Z68.36","Z98.84","K91.89","R11.2","E22.1","F31.9","N52.9","N62.","S01.81XA","W27.8XXA","R68.82","H92.01","Z80.41","Z80.8","Z84.81","Z80.6","Z80.52","Z80.0","Z80.3","Z12.11","E66.01","Z68.35","R10.13","K21.00","R13.10","T85.898A","S61.451A","W54.0XXA","R29.898","K20.91","K94.23","S20.212A","S05.01XA"],"date":["2021-02-22","2021-02-22","2021-02-22","2022-08-17","2022-08-17","2022-08-17","2021-11-18","2022-03-29","2021-11-18","2021-11-18","2021-12-07","2022-05-06","2021-12-07","2021-08-27","2021-08-27","2021-08-27","2021-08-27","2021-07-18","2021-07-18","2021-08-09","2021-01-12","2021-01-19","2021-01-19","2021-01-19","2021-01-19","2021-01-19","2021-01-19","2021-01-19","2022-05-28","2021-07-01","2021-07-01","2021-07-01","2021-08-09","2021-08-09","2021-11-18","2021-11-17","2021-11-17","2022-03-15","2022-03-29","2022-03-29","2022-02-04","2022-02-23"],"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":{"indx":[false,false],"comment":["",""],"score":["",""]}},{"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":[["","00054040113","DESVENLAFAX","TAB 100MG ER","30","Select","Select",""],["","64380073706","VITAMIN","CAP 50000UNT","13","Select","Select",""],["","61958200201","DESCOVY","TAB 200\/25MG","30","Select","Select",""],["","57237016250","OMEPRAZOLE","CAP 40MG","-180","Select","Select",""],["","00406895601","AMPHET\/DEXTR","CAP 30MG ER","-60","Select","Select",""],["","00781531810","ZOLPIDEM","TAB 10MG","30","Select","Select",""],["","65862050320","AMOX\/K","TAB 875-125","10","Select","Select",""],["","54092039101","ADDERALL","CAP 30MG","60","Select","Select",""],["","70069000510","CYANOCOBALAM","INJ 1000MCG","6","Select","Select",""],["","08290305270","3ML","MIS 25GX1\"","6","Select","Select",""],["","31722070590","VALACYCLOVIR","TAB 1GM","-30","Select","Select",""],["","00006483703","PNEUMOVAX","INJ 25\/0.5","0","Select","Select",""],["","33332032101","AFLURIA","INJ 2021-22","0","Select","Select",""],["","00591352530","LIDOCAINE","PAD 0.05","10","Select","Select",""],["","52817033200","CYCLOBENZAPR","TAB 10MG","30","Select","Select",""],["","16571020150","DICLOFENAC","TAB 75MG DR","30","Select","Select",""],["","59762040101","SUCRALFATE","TAB 1GM","360","Select","Select",""],["","42794001710","ASENAPINE","SUB 10MG","90","Select","Select",""],["","24208029505","TOBRA\/DEXAME","SUS 0.3-0.1%","5","Select","Select",""],["","43598016630","OLANZAPINE","TAB 10MG","30","Select","Select",""],["","00781261305","AMOXICILLIN","CAP 500MG","30","Select","Select",""],["","00116200116","CHLORHEX","SOL 0.0012","473","Select","Select",""],["","59267030402","PFIZER","INJ BA4\/BA5","0","Select","Select",""],["","57237023301","SMZ-TMP","TAB 800-160","20","Select","Select",""],["","00406048401","APAP\/CODEINE","TAB 300-30MG","10","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":{"indx":[["","","",""],[""],[""],[""],[""],[""]],"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":""}]}]}