{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" IRRETELTTIL","gend":1,"add":"T91 6169TS YAB H","city":"NORFOLK","state":"VA","zip":"23518-9998","dob":"1992-08-25","age":"","mstatus":"","insh":"6068210*91","cliId":"","pno":"57\/7574191-2","cno":"757\/617-4050","email":"","ename":"","eno":"","pphy":"ONEAL, ALICIA D PA","ppno":"757\/261-5999","pcpadd":"850 KEMPSVILLE RD STE 200B","pcpcity":"NORFOLK","pcpstate":"VA","pcpzip":23502,"pcpcounty":"","pcpid":"","pcpname":"SMG - Sentara Walk In Care Kempsville","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","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":["O26.891","R10.30","Z3A.00","L74.510","L70.9","V23.41","Z3A.26","O99.89","S00.212A","R51.","M54.5","N76.0","R10.32","O20.9","Z30.2","N39.0","R10.2","R35.0","Z39.1","Z34.82","Z34.83","M25.521","M25.511","N92.6","N89.8","Z32.02","N90.89","Z01.411","Z12.39","N94.10","Z3A.17","Z3A.28","Z3A.29","Z05.8","F33.1","Z01.818","Z11.3","Z11.4","O03.4","Z72.0","O21.0","Z3A.24","Z3A.33","Z36.89","O04.89","Z09.","R30.9","O00.102","O03.39","O02.1","N30.01","Z3A.16","Z34.90","O36.8310","O23.591","B37.3","Z3A.10","O23.592","Z3A.20","O80.","V58.89","V49.50XD","Z20.2","S31.41XA","O04.6","M54.2","Z20.822","Z90.79","F17.210","Z91.011","N80.9","Z32.01","Z48.89","Z64.0","Z33.2","Z12.4","Z11.51","Z3A.18","Z3A.21","Z3A.30","Z3A.31","Z3A.36","O99.019","Z37.0","Z3A.38","O99.344","O99.334","F41.9","Z86.59","S13.4XXA","Z20.828","O73.1","E73.9","M54.9","R10.9","Z3A.01","R10.33","O21.9","Z3A.22","R31.9","Z3A.27","S16.1XXA","V49.50XA","F32.9","Z39.2","Y92.411","S39.012A","F33.2","F41.1","O46.90","R53.83","E55.9"],"date":["2019-02-27","2021-11-17","2021-03-15","2019-04-30","2019-04-30","2020-01-17","2019-11-27","2020-02-06","2020-03-13","2020-03-13","2020-04-27","2020-08-18","2020-08-18","2021-03-15","2021-03-19","2021-08-11","2021-09-03","2021-11-17","2020-02-03","2020-02-03","2020-02-07","2020-05-28","2020-05-28","2020-06-10","2021-02-26","2020-10-06","2020-12-03","2021-09-03","2021-09-03","2021-09-03","2019-10-01","2019-12-12","2019-12-19","2020-03-14","2020-03-30","2021-03-17","2020-07-18","2020-07-18","2021-01-06","2021-08-26","2019-03-17","2019-11-14","2020-01-17","2020-01-17","2021-01-05","2021-02-26","2021-02-26","2021-03-19","2021-03-19","2021-01-08","2019-04-18","2019-09-24","2019-11-25","2019-08-08","2019-08-08","2019-08-08","2019-08-08","2019-10-22","2019-10-23","2020-02-20","2020-06-01","2020-06-01","2020-06-16","2021-07-13","2019-03-29","2020-04-27","2021-03-17","2021-07-13","2021-08-26","2021-07-13","2021-08-26","2019-07-03","2019-04-12","2019-04-12","2019-04-12","2019-07-03","2019-07-03","2019-10-15","2019-10-29","2019-12-27","2020-01-03","2020-02-07","2020-02-07","2020-02-20","2020-02-20","2020-02-20","2020-02-20","2020-02-20","2020-02-20","2020-03-31","2021-01-06","2021-01-06","2021-08-26","2021-08-26","2019-02-27","2019-07-21","2019-04-03","2019-07-21","2019-11-05","2019-12-05","2019-12-05","2020-04-10","2020-04-10","2020-03-30","2020-03-30","2020-04-10","2020-04-10","2020-06-03","2020-06-03","2021-03-15","2021-10-06","2021-10-06"],"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":[["","","METRONIDAZOL"," METRONIDAZOL ","14","Select","Select",""],["","47781030301","NITROFURANTN","CAP 100MG","14","Select","Select",""],["","","FLUCONAZOLE"," FLUCONAZOLE ","1","Select","Select",""],["","","APAP\/CODEINE"," APAP\/CODEINE ","15","Select","Select",""],["","50383077504","LIDOCAINE","SOL 2% VISC","226","Select","Select",""],["","00046087221","PREMARIN","CRE 0.625MG","30","Select","Select",""],["","68180018001","CEFADROXIL","CAP 500MG","10","Select","Select",""],["","","AZITHROMYCIN"," AZITHROMYCIN ","6","Select","Select",""],["","75826011510","PHENAZOPYRID","TAB 200MG","15","Select","Select",""],["","","OXYCOD\/APAP","TAB 5-325MG","","Select","Select",""],["","70436001002","BUPROPN","TAB 150MG XL","30","Select","Select",""],["","","ETONOGESTREL","MIS ETHY EST","","Select","Select",""],["","63304069301","CLINDAMYCIN","CAP 300MG","14","Select","Select",""],["","","IBUPROFEN"," IBUPROFEN ","30","Select","Select",""],["","","DOXYCYCL","TAB 100MG","","Select","Select",""],["","","NAPROXEN"," NAPROXEN ","20","Select","Select",""],["","","DOCUSATE","CAP 100MG","","Select","Select",""],["","","STOOL","TAB 8.6-50MG","","Select","Select",""],["","","CVS","CHW 80MG","","Select","Select",""],["","","RANITIDINE","SYP 75MG\/5ML","","Select","Select",""],["","","BUSPIRONE","TAB 15MG","","Select","Select",""],["","","CHLORZOXAZON","TAB 500MG","","Select","Select",""],["","","AMOX\/K","TAB 875-125","","Select","Select",""],["","","AFTERA","TAB 1.5MG","","Select","Select",""],["","","NYSTAT\/TRIAM","CRE ","","Select","Select",""],["","","FERROUS","TAB 325MG","","Select","Select",""],["","","FLUOXETINE","CAP 20MG","","Select","Select",""],["","","CYCLOBENZAPR","TAB 10MG","","Select","Select",""],["","","LAMOTRIGINE","TAB 25MG","","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":""}]}]}