{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"SAMANTHA BARKER","gend":1,"add":"1013   PRINCESS ANNE STREET                                 ","city":"FREDERICKSBURG                ","state":"VA","zip":"22401-3835","dob":"1991-11-01","age":"","mstatus":"","insh":10048154,"cliId":"","pno":5406842943,"cno":5403107006,"email":"","ename":"","eno":"","pphy":"ANSARI, NATHER B                                            ","ppno":"","pcpadd":"1075 GARRISONVILLE RD,Ste 115","pcpcity":"STAFFORD                      ","pcpstate":"VA","pcpzip":225568600,"pcpcounty":"","pcpid":"P0125879","pcpname":"SENIOR AND ADULT CARE LLC","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"CENTRAL","aligned":"","ano":"","add2":"APT 11                                                      ","add3":"","madd1":"1013   PRINCESS ANNE STREET                                 ","madd2":"APT 11                                                      ","madd3":"","mcity":"FREDERICKSBURG                ","mstate":"VA","mzip":"22401-3835","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","1","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R53.1","M54.9","M79.10","F31.9","F41.9","J45.909","K31.84","M41.9","F17.200","F98.8","Z88.0","Z88.1","Z91.040","Z88.5","J06.9","J45.20","R07.9","K21.9","Z88.3","R91.8","R05","G43.009","Z88.2","R52","G44.89","N76.0","B96.89","Z20.2","F17.210","N93.9","Z79.51","M54.5","S39.92XA","W01.0XXA","Y92.480","K58.9","E28.2","M25.571","W19.XXXA","Y93.01","N72","M79.671","R10.2","N89.8","R26.81","K59.00","Z90.49","R10.9","R11.10","N39.0","A59.01","Z11.3","N83.201","K44.9","F39","N73.9","B37.3","R10.31","R10.32","G47.00","R68.89","R11.0","B00.89","R21","G43.909","K62.5","A60.04","N30.90","N30.00","Z33.1","N91.1","O36.80X0","O26.891","O99.511","Z3A.09","O99.341","F99","O99.281","O20.9","Z87.891","R11.2","Z13.79","Z3A.13","Z34.82","O23.591","Z3A.12","O99.611","O99.351","O99.89","R19.7","O21.9","O26.892","R10.84","O99.512","O99.342","Z3A.14","R39.9","O99.612","Z87.19","O99.282","Z3A.18","Z98.890","Z3A.19","Z36.9","Z36.86","K58.1","O23.12","O21.2","Z3A.26","O26.893","O26.853","O99.513","O09.293","O09.213","Z3A.28","O46.93","O35.9XX9","Z34.03","Z13.1","O47.03","Z3A.29","O60.00","Z3A.00","O60.03","D64.9","Z3A.32","R10.30","Z39.1","Z34.83","O09.893","Z3A.35","O36.5930","O36.8390","O36.8330","Z36.85","Z3A.36","Z3A.37","O99.613","O99.324","O99.824","O99.02","O99.52","O99.344","O76","Z23","O99.284","Z37.0","F19.10","Z3A.38","O99.334","G89.18","O36.5990","Z37.9","Z39.0","F51.01","R53.83","R01.1","Q25.0","Q21.1","R00.2","S39.012A","X58.XXXA","Y92.89","Y93.89","X50.0XXA","M47.816","M54.30","M41.50","R07.89","Z20.828","R06.02","J45.901","Z86.59","R06.00","S29.012A","R09.89","R30.0","Z87.42","S93.601A","Z00.01","Z13.220","Z71.89","Z13.31","F43.10","Z01.82","R53.81","Z20.822","Z59.0","I49.8","I45.0","F12.20","Z3A.01","Z3A.08","O99.331","O20.0","R82.71","O21.0","Z36.89","G43.809","Z3A.10","K92.89","K31.89"],"date":["2019-01-16","2020-09-28","2019-01-19","2021-09-30","2020-08-18","2020-08-18","2021-09-30","2021-01-21","2019-10-30","2021-09-30","2020-06-19","2020-06-19","2020-06-19","2020-06-19","2020-10-31","2019-02-08","2020-10-30","2021-10-04","2020-01-31","2019-02-08","2021-08-11","2020-03-07","2019-02-13","2019-10-30","2019-02-13","2019-06-04","2021-10-14","2021-09-27","2021-09-16","2019-02-22","2019-02-22","2020-09-30","2019-03-10","2019-03-11","2019-03-11","2020-02-20","2021-10-21","2019-03-21","2019-03-21","2019-03-21","2019-03-21","2021-01-05","2021-10-14","2021-10-14","2019-03-21","2021-09-14","2021-10-21","2021-09-30","2019-04-20","2021-10-04","2019-05-23","2020-02-11","2019-07-20","2019-06-02","2019-06-17","2019-06-28","2020-12-30","2021-09-16","2019-06-28","2019-07-03","2020-08-04","2021-09-16","2019-07-17","2019-11-18","2021-10-21","2019-11-18","2019-12-11","2019-12-11","2020-01-05","2020-01-05","2021-09-17","2020-01-14","2021-09-16","2020-02-20","2020-01-31","2021-09-30","2021-09-30","2021-10-21","2020-01-31","2021-10-21","2021-01-16","2020-02-11","2020-03-03","2020-07-13","2021-09-30","2020-02-20","2021-10-21","2021-10-21","2020-03-31","2020-03-03","2020-03-03","2020-03-09","2021-09-14","2020-03-03","2020-05-26","2020-03-03","2021-11-03","2020-03-31","2021-10-21","2020-05-26","2020-03-31","2021-01-15","2020-04-09","2020-04-09","2020-04-09","2020-04-16","2020-05-26","2020-05-26","2020-05-26","2020-06-07","2020-06-07","2020-06-07","2020-07-28","2020-07-10","2020-06-07","2020-06-07","2021-11-03","2020-07-30","2020-06-09","2020-07-10","2020-06-19","2020-06-19","2020-08-19","2020-06-19","2020-08-18","2020-07-10","2020-11-21","2020-08-20","2020-07-13","2020-08-04","2020-07-28","2020-08-18","2020-08-04","2020-08-18","2020-07-30","2020-08-04","2020-08-11","2020-08-11","2020-08-18","2020-08-18","2020-08-18","2020-08-18","2020-08-18","2020-08-18","2020-08-18","2020-08-18","2020-08-18","2020-08-18","2020-08-18","2020-08-18","2020-09-13","2020-08-19","2020-08-19","2020-08-21","2020-09-09","2020-09-09","2020-09-16","2021-08-31","2021-08-31","2021-08-31","2020-09-28","2021-01-05","2021-01-05","2021-01-05","2020-09-28","2020-09-30","2020-09-30","2020-09-30","2020-10-30","2020-10-31","2020-11-07","2020-11-07","2021-07-24","2020-11-01","2020-11-07","2020-11-07","2021-02-16","2020-11-21","2021-01-05","2021-02-16","2021-02-16","2021-02-16","2021-02-16","2021-02-19","2021-03-13","2021-05-08","2021-08-11","2021-08-11","2021-08-31","2021-08-31","2021-09-15","2021-09-30","2021-09-14","2021-09-16","2021-09-16","2021-09-16","2021-09-16","2021-09-30","2021-10-21","2021-10-21","2021-10-21","2021-10-21"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",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":[["","49884068901","METOCLOPRAM","10MG","30","Select","Select",""],["","63868032808","QC","10MG","8","Select","Select",""],["","67405060301","FLUCONAZOLE","150MG","1","Select","Select",""],["","42571025201","CLINDAMYCIN","300MG","14","Select","Select",""],["","31722070430","VALACYCLOVIR","500MG","90","Select","Select",""],["","00591565810","CYCLOBENZAPR","10MG","21","Select","Select",""],["","00527133010","BACLOFEN","10MG","60","Select","Select",""],["","61442010201","DICLOFENAC","50MG DR","60","Select","Select",""],["","68180016013","AZITHROMYCIN","250MG","6","Select","Select",""],["","55111015905","OMEPRAZOLE","40MG","30","Select","Select",""],["","65162019050","NAPROXEN","500MG","30","Select","Select",""],["","59779065034","CVS","ROWSY TUS","237","Select","Select",""],["","00093317431","ALBUTEROL","E","8.5","Select","Select",""],["","59310057922","PROAIR","","8.5","Select","Select",""],["","00378064205","PREDNISONE","20MG","15","Select","Select",""],["","23155065201","METRONIDAZOL","500MG","14","Select","Select",""],["","65862039010","ONDANSETRON","4MG ODT","20","Select","Select",""],["","51672300302","HYDROCORT","2.50%","28.35","Select","Select",""],["","60258019701","PRENATAL","TAB","90","Select","Select",""],["","68382080510","TRAZODONE","50MG","30","Select","Select",""],["","00185012201","NITROFURANTN","100MG","10","Select","Select",""],["","00245086070","VANDAZOLE","0.75%","70","Select","Select",""],["","50428026926","GLYCERIN","2GM","25","Select","Select",""],["","00904759060","FEROSUL","325MG","60","Select","Select",""],["","70700026894","FOSFOMYCIN","3GM","1","Select","Select",""],["","00406051201","OXYCOD\/APAP","5-325MG","30","Select","Select",""],["","00904671980","ACETAMINOPHEN","B 325","30","Select","Select",""],["","68180012101","CEPHALEXIN","250MG","21","Select","Select",""],["","43386009019","GAVILYTE-G","","4,000.00","Select","Select",""],["","45802086866","POLYETH","3350 NF","10","Select","Select",""],["","47781030801","NITROFUR","100MG","10","Select","Select",""],["","43598021050","SSD","1%","50","Select","Select",""],["","50428166371","BISACODYL","10MG","6","Select","Select",""],["","49483060350","IBUPROFEN","600MG","28","Select","Select",""],["","57664037718","TRAMADOL","50MG","15","Select","Select",""],["","49884068901","METOCLOPRAM ","TAB 10MG","30","Select","Select",""],["","63868032808","QC ","SUP 10MG","8","Select","Select",""],["","67405060301","FLUCONAZOLE ","TAB 150MG","1","Select","Select",""],["","42571025201","CLINDAMYCIN ","CAP 300MG","14","Select","Select",""],["","57237007710","ONDANSETRON ","TAB 4MG ODT","30","Select","Select",""],["","10006073017","VITAMIN ","TAB 50MG","60","Select","Select",""],["","13925011701","SE-NATAL ","CHW ","30","Select","Select",""],["","31722070430","VALACYCLOVIR ","TAB 500MG","90","Select","Select",""],["","00591565810","CYCLOBENZAPR ","TAB 10MG","21","Select","Select",""],["","00527133010","BACLOFEN ","TAB 10MG","60","Select","Select",""],["","61442010201","DICLOFENAC ","TAB 50MG DR","60","Select","Select",""],["","68180016013","AZITHROMYCIN ","TAB 250MG","6","Select","Select",""],["","55111015905","OMEPRAZOLE ","CAP 40MG","30","Select","Select",""],["","65162019050","NAPROXEN ","TAB 500MG","30","Select","Select",""],["","59779065034","CVS ","N-D ROWSY TUS","237","Select","Select",""],["","00093317431","ALBUTEROL ","FAT E","8.5","Select","Select",""],["","59310057922","PROAIR ","AER ","8.5","Select","Select",""],["","00378064205","PREDNISONE ","TAB 20MG","15","Select","Select",""],["","23155065201","METRONIDAZOL ","TAB 500MG","14","Select","Select",""],["","51672300302","HYDROCORT ","CRE 0.025","28.35","Select","Select",""],["","60258019701","PRENATAL ","CHW TAB","90","Select","Select",""],["","68382080510","TRAZODONE ","TAB 50MG","30","Select","Select",""],["","00185012201","NITROFURANTN ","CAP 100MG","10","Select","Select",""],["","00245086070","VANDAZOLE ","GEL 0.0075","70","Select","Select",""],["","50428026926","GLYCERIN ","SUP 2GM","25","Select","Select",""],["","00904759060","FEROSUL ","TAB 325MG","60","Select","Select",""],["","70700026894","FOSFOMYCIN ","POW 3GM","1","Select","Select",""],["","00406051201","OXYCOD\/APAP ","TAB 5-325MG","30","Select","Select",""],["","00904671980","ACETAMINOPHEN ","TA B 325","30","Select","Select",""],["","68180012101","CEPHALEXIN ","CAP 250MG","21","Select","Select",""],["","43386009019","GAVILYTE-G ","SOL ","4,000.00","Select","Select",""],["","45802086866","POLYETH ","POW 3350 NF","10","Select","Select",""],["","47781030801","NITROFUR ","CAP 100MG","10","Select","Select",""],["","43598021050","SSD ","CRE 0.01","50","Select","Select",""],["","50428166371","BISACODYL ","SUP 10MG","6","Select","Select",""],["","49483060350","IBUPROFEN ","TAB 600MG","28","Select","Select",""],["","57664037718","TRAMADOL ","TAB 50MG","15","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","",""],["N\/A","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["Yes","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":""}]}]}