{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DOROTHY FORTE","gend":1,"add":"331NICHOLSON STREET  ","city":"NORFOLK  ","state":"VA","zip":"23510-3004","dob":"1954-08-19","age":"","mstatus":"","insh":11002693,"cliId":"3F48T68VD25","pno":7579073767,"cno":7577691746,"email":"","ename":"","eno":"","pphy":"HUMADI, SAHIRA A  ","ppno":7574465955,"pcpadd":"1701 High St,Fl 1","pcpcity":"Portsmouth  ","pcpstate":"VA","pcpzip":237043103,"pcpcounty":"","pcpid":"P9058623","pcpname":"EVMS HEALTH SERVICES","plan":"VPHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"","add2":"","add3":"","madd1":"331NICHOLSON STREET  ","madd2":"","madd3":"","mcity":"NORFOLK  ","mstate":"VA","mzip":"23510-3004","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","1","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Current Conditions \/ Suspect Codes","q":[{"a":{"diag":["L30.9","H40.1113","H40.1122","H31.091","H40.1132","H16.143","H47.011","D48.5","L29.9","L66.9","L65.8","L40.8","I10","E78.5","F33.9","M54.9","D17.9","K59.00","F17.200","E66.9","Z11.59","Z00.00","Z68.31","F32.89","E78.2","E55.9","Z12.11","L40.9","M25.561","Z87.891","Z12.31","Z80.3","O21.2","R19.7","Z3A.34","L84","F17.210","Z79.899","L81.9","L60.8","M20.12","M20.11","M20.41","M20.42","R42","R07.9","I25.2","Z86.19","Z90.710","M51.36","M54.5","Z91.81","W19.XXXA","Y92.009","M17.11","M19.042","M19.041","M22.2X1","S39.012A","M47.816","M79.641","M79.642","Z68.34","R21","D17.20","R23.2","M79.622","M79.621","N64.4","R59.0","L81.0","L30.4","F43.20","R06.00","J44.1","R06.02","R05","F32.9","F41.9","Z63.4","F43.9","J44.9","R49.0","I34.0","I36.1","R60.9","Z12.2","E27.8","I08.3","R91.8","R93.7","R06.09","Z82.49","Z79.82","Z13.31","R10.11"],"date":["2021-09-08","2018-01-17","2020-05-19","2018-01-17","2019-01-21","2019-01-21","2019-01-21","2021-07-16","2020-08-19","2018-02-06","2018-02-06","2020-08-19","2021-11-10","2021-10-25","2021-09-08","2019-04-10","2021-06-17","2019-09-13","2021-10-01","2018-07-31","2018-04-11","2021-10-25","2018-07-31","2018-04-11","2018-04-11","2018-04-11","2021-09-08","2021-10-13","2019-06-11","2021-10-08","2020-07-28","2018-06-19","2019-07-12","2019-07-12","2019-07-12","2018-07-31","2021-11-10","2021-10-13","2021-07-16","2020-08-18","2018-08-29","2018-08-29","2018-08-29","2018-08-29","2019-09-13","2018-09-21","2021-11-10","2018-09-21","2018-09-21","2020-10-06","2021-09-08","2020-10-06","2020-10-06","2020-10-06","2019-12-05","2019-12-05","2019-12-05","2019-12-05","2019-12-05","2019-12-05","2019-10-24","2019-10-24","2019-12-05","2019-12-13","2021-03-22","2021-03-25","2021-06-17","2021-06-17","2021-06-17","2021-06-17","2021-07-16","2021-09-09","2021-09-08","2021-10-08","2021-10-01","2021-10-01","2021-09-12","2021-09-12","2021-09-12","2021-09-12","2021-09-12","2021-10-01","2021-10-01","2021-10-04","2021-10-04","2021-10-04","2021-10-04","2021-10-15","2021-10-04","2021-10-04","2021-10-04","2021-10-08","2021-10-08","2021-10-08","2021-10-25","2021-11-10"],"priorHcc":["","","","","","","","","","","","",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":{"indx":["","",""],"comment":["","",""],"sub":[]}},{"a":{"indx":["","",""],"comment":["","",""],"sub":[]}}]},{"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":[["","70700010617","CLOBETASOL","OIN 0.0005","","Select","Select",""],["","55513013760","OTEZLA","TAB 30MG","","Select","Select",""],["","67877019905","AMLODIPINE","TAB 10MG","","Select","Select",""],["","29300012810","HYDROCHLOROT","TAB 25MG","","Select","Select",""],["","65862005290","SIMVASTATIN","TAB 20MG","","Select","Select",""],["","59746021106","CYCLOBENZAPR","TAB 5MG","","Select","Select",""],["","74153903","HUMIRA PEN","KIT PS\/UV","","Select","Select",""],["","16571020110","DICLOFENAC","TAB 75MG DR","","Select","Select",""],["","45802005505","TRIAMCINOLON","OIN 0.001","","Select","Select",""],["","51672129803","KETOCONAZOLE","CRE 0.02","","Select","Select",""],["","68462029792","CICLOPIROX","CRE 0.0077","","Select","Select",""],["","68382003506","VENLAFAXINE","CAP 75MG ER","","Select","Select",""],["","23921105","COMBIGAN","SOL 0.2\/0.5%","","Select","Select",""],["","6483703","PNEUMOVAX 23","INJ 25\/0.5","","Select","Select",""],["","49281040565","FLUZONE HD","INJ PF 19-20","","Select","Select",""],["","70461012003","FLUAD QUADRI","INJ 0.5ML","","Select","Select",""],["","31722094101","HYDROCO\/APAP","TAB 5-325MG","","Select","Select",""],["","33332031801","AFLURIA QUAD","INJ PF 18-19","","Select","Select",""],["","70700010617","CLOBETASOL ","OIN 0.0005","60","Select","Select",""],["","55513013760","OTEZLA ","TAB 30MG","60","Select","Select",""],["","67877019905","AMLODIPINE ","TAB 10MG","90","Select","Select",""],["","65862005290","SIMVASTATIN ","TAB 20MG","90","Select","Select",""],["","29300012810","HYDROCHLOROT ","TAB 25MG","90","Select","Select",""],["","51672129803","KETOCONAZOLE ","CRE 0.02","60","Select","Select",""],["","68382003506","VENLAFAXINE ","CAP 75MG ER","30","Select","Select",""],["","59746021106","CYCLOBENZAPR ","TAB 5MG","30","Select","Select",""],["","31722094101","HYDROCO\/APAP ","TAB 5-325MG","10","Select","Select",""],["","74153903","HUMIRA ","KIT PS\/UV","3","Select","Select",""],["","16571020110","DICLOFENAC ","TAB 75MG DR","180","Select","Select",""],["","68462029792","CICLOPIROX ","CRE 0.0077","90","Select","Select",""],["","45802005505","TRIAMCINOLON ","OIN 0.001","454","Select","Select",""],["","23921105","COMBIGAN ","SOL 0.2\/0.5%","5","Select","Select",""],["","70461012003","FLUAD ","INJ 0.5ML","0.5","Select","Select",""],["","6483703","PNEUMOVAX ","INJ 25\/0.5","0.5","Select","Select",""],["","33332031801","AFLURIA ","INJ PF 18-19","0.5","Select","Select",""],["","49281040565","FLUZONE ","PF 19-20","0.5","Select","Select",""],["","00074153903","HUMIRA","PS\/UV","3","Select","Select",""],["","70461012003","FLUAD","0.5ML","0.5","Select","Select",""],["","45802049326","AMMONIUM","0.12","385","Select","Select",""],["","49281040565","FLUZONE","PF 19-20","0.5","Select","Select",""],["","00006483703","PNEUMOVAX","25\/0.5","0.5","Select","Select",""],["","33332031801","AFLURIA","PF 18-19","0.5","Select","Select",""],["","00168014630","HYDROCORT","2.50%","28.35","Select","Select",""],["","68180096301","ALBUTEROL","HFA","8.5","Select","Select",""],["","62332025118","AZITHROMYCIN","250MG","6","Select","Select",""],["","59746017506","PREDNISONE","20MG","10","Select","Select",""],["","72647033104","METHYLPRED","4MG","21","Select","Select",""],["","00168014630","HYDROCORT ","OIN 0.025","28.35","Select","Select",""],["","68180096301","ALBUTEROL ","AER HFA","8.5","Select","Select",""],["","00591079501","DICYCLOMINE ","TAB 20MG","30","Select","Select",""],["","59746017506","PREDNISONE ","TAB 20MG","10","Select","Select",""],["","45802049326","AMMONIUM ","CRE 0.12","385","Select","Select",""],["","00115175308","ACITRETIN ","CAP 25MG","30","Select","Select",""],["","72647033104","METHYLPRED ","TAB 4MG","21","Select","Select",""],["","62332025118","AZITHROMYCIN ","TAB 250MG","6","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":[[["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["No","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":""}]}]}