{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"GWEN   E BERGER","gend":1,"add":"641   DEERVIEW ROAD                                         ","city":"GRETNA                        ","state":"VA","zip":"24557-3546","dob":"1962-09-10","age":"","mstatus":"","insh":10051298,"cliId":"","pno":4342512557,"cno":4347091922,"email":"","ename":"","eno":"","pphy":"BURKHOLDER, BRENDEN                                         ","ppno":"","pcpadd":"2900 LAMB CIRCLE,Ste A","pcpcity":"CHRISTIANSBURG                ","pcpstate":"VA","pcpzip":240736344,"pcpcounty":"","pcpid":"P9058480","pcpname":"CENTRA MEDICAL GROUP","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"LOT 3                                                       ","add3":"","madd1":"641   DEERVIEW ROAD                                         ","madd2":"LOT 3                                                       ","madd3":"","mcity":"GRETNA                        ","mstate":"VA","mzip":"24557-3546","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","1","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["L20.84","R68.89","F33.3","B35.1","L60.3","Z79.899","E11.42","H66.91","S09.91XA","H40.013","H25.13","L85.3","R11.10","E11.65","E11.9","I25.10","I10","J45.909","I25.2","Z79.84","Z79.82","F17.210","L60.0","E11.8","R11.0","Z88.5","Z88.8","R91.8","R10.9","R16.0","R07.89","F32.9","E87.6","E78.5","Z82.49","R07.9","R51","R55","R00.2","E78.2","Z72.0","E55.9","R92.2","Z12.31","Z80.0","N64.89","R92.8","M54.5","B35.3","Z23","J06.9","Z20.828","R05","R07.82","T78.40XA","T78.3XXA","K59.00","K12.1","M79.672","L03.032","M79.675","R52","S91.102A","R42","E11.22","I12.9","S91.102D"],"date":["2019-04-29","2021-02-15","2021-09-13","2021-10-19","2021-10-19","2021-04-04","2021-10-19","2019-04-01","2019-04-01","2021-06-22","2021-06-22","2021-02-15","2019-06-09","2019-06-09","2021-08-25","2021-05-20","2021-05-20","2021-04-04","2020-12-02","2020-12-02","2021-04-04","2020-12-02","2019-10-31","2019-07-31","2019-11-14","2021-04-04","2021-04-04","2019-09-24","2020-04-21","2019-09-24","2019-11-11","2020-10-19","2021-06-02","2021-05-20","2021-05-20","2021-05-20","2019-12-02","2021-05-20","2021-05-20","2021-05-20","2021-05-20","2019-12-20","2019-12-20","2020-02-12","2020-03-11","2020-03-11","2020-03-11","2020-04-14","2020-10-13","2021-04-13","2020-10-19","2020-10-19","2020-10-19","2020-11-18","2020-12-02","2020-12-10","2020-12-16","2021-01-19","2021-02-15","2021-06-09","2021-04-04","2021-04-04","2021-06-09","2021-05-20","2021-08-30","2021-08-30","2021-07-14"],"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":[["","27241000406","RISPERIDONE","2MG","30","Select","Select",""],["","67877025001","QUETIAPINE","100MG","30","Select","Select",""],["","68382009405","CARVEDILOL","12.5MG","60","Select","Select",""],["","00378395305","ATORVASTATIN","80MG","30","Select","Select",""],["","62135098505","DOXYCYCL","100MG","20","Select","Select",""],["","67877021901","CEPHALEXIN","500MG","30","Select","Select",""],["","51991001406","MELATONIN","3MG","30","Select","Select",""],["","69315090510","LORAZEPAM","1MG","90","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","27808003503","HYDROCO\/APAP","5-325MG","15","Select","Select",""],["","67877056310","METFORMIN","1000MG","120","Select","Select",""],["","65862001305","SERTRALINE","100MG","60","Select","Select",""],["","45802091987","CETIRIZINE","10MG","30","Select","Select",""],["","00054327099","FLUTICASONE","50MCG","16","Select","Select",""],["","00173068220","VENTOLIN","","54","Select","Select",""],["","57237023305","SMZ-TMP","800-160","20","Select","Select",""],["","43547039711","HYDROCHLOROT","25MG","90","Select","Select",""],["","00591544310","PREDNISONE","20MG","20","Select","Select",""],["","65862085901","FAMOTIDINE","20MG","10","Select","Select",""],["","55111012705","CIPROFLOXACN","500MG","14","Select","Select",""],["","30768015605","VITAMIN","1000UNIT","90","Select","Select",""],["","00378456105","POT CHLORIDE","10MEQ ER","30","Select","Select",""],["","51672208002","TERBINAFINE","1%","30","Select","Select",""],["","42571016201","AMOX\/K","875-125","14","Select","Select",""],["","74312015605","D3-1000","1000UNIT","30","Select","Select",""],["","43547035610","LISINOPRIL","40MG","30","Select","Select",""],["","45802086802","POLYETH","3350 NF","238","Select","Select",""],["","57896040110","DOCUSATE","100MG","20","Select","Select",""],["","40565011527","SOLOSITE","WOUND","85","Select","Select",""],["","70000018003","8","650MG","90","Select","Select",""],["","00904671980","ACETAMINOPHEN","B 325","120","Select","Select",""],["","57896098110","ASPIRIN","81MG EC","30","Select","Select",""],["","63868008210","PAIN","325MG","120","Select","Select",""],["","00031223413","DIMETAPP","COLD\/CGH","118","Select","Select",""],["","55111068305","IBU","600MG","60","Select","Select",""],["","00536101810","TRAVEL","25MG","20","Select","Select",""],["","57237007710","ONDANSETRON","4MG ODT","10","Select","Select",""],["","76204060030","IPRATROPIUM\/","ALBUTER","90","Select","Select",""],["","45802049326","AMMONIUM","12%","385","Select","Select",""],["","45802011222","MUPIROCIN","2%","22","Select","Select",""],["","27241000406","RISPERIDONE ","TAB 2MG","30","Select","Select",""],["","67877025001","QUETIAPINE ","TAB 100MG","30","Select","Select",""],["","68382009405","CARVEDILOL ","TAB 12.5MG","60","Select","Select",""],["","00378395305","ATORVASTATIN ","TAB 80MG","30","Select","Select",""],["","62135098505","DOXYCYCL ","CAP 100MG","20","Select","Select",""],["","80777027315","MODERNA ","INJ COVID-19","0.5","Select","Select",""],["","67877021901","CEPHALEXIN ","CAP 500MG","30","Select","Select",""],["","51991001406","MELATONIN ","TAB 3MG","30","Select","Select",""],["","69315090510","LORAZEPAM ","TAB 1MG","90","Select","Select",""],["","16729021716","SERTRALINE ","TAB 100MG","60","Select","Select",""],["","66993001968","ALBUTEROL ","AER HFA","18","Select","Select",""],["","27808003503","HYDROCO\/APAP ","TAB 5-325MG","15","Select","Select",""],["","67877056301","METFORMIN ","TAB 1000MG","180","Select","Select",""],["","45802091987","CETIRIZINE ","TAB 10MG","30","Select","Select",""],["","00054327099","FLUTICASONE ","SPR 50MCG","16","Select","Select",""],["","00173068220","VENTOLIN ","AER ","54","Select","Select",""],["","57237023305","SMZ-TMP ","TAB 800-160","20","Select","Select",""],["","43547039711","HYDROCHLOROT ","TAB 25MG","90","Select","Select",""],["","00591544310","PREDNISONE ","TAB 20MG","20","Select","Select",""],["","65862085901","FAMOTIDINE ","TAB 20MG","10","Select","Select",""],["","55111012705","CIPROFLOXACN ","TAB 500MG","14","Select","Select",""],["","30768015605","VITAMIN ","CAP 1000UNIT","90","Select","Select",""],["","00378456105","POT  CHLORIDE","TAB 10MEQ ER","30","Select","Select",""],["","51672208002","TERBINAFINE ","CRE 0.01","30","Select","Select",""],["","42571016201","AMOX\/K ","TAB 875-125","14","Select","Select",""],["","74312015605","D3-1000 ","CAP 1000UNIT","30","Select","Select",""],["","43547035610","LISINOPRIL ","TAB 40MG","30","Select","Select",""],["","45802086802","POLYETH ","POW 3350 NF","238","Select","Select",""],["","57896040110","DOCUSATE ","CAP 100MG","20","Select","Select",""],["","40565011527","SOLOSITE ","GEL WOUND","85","Select","Select",""],["","00904671980","ACETAMINOPHEN ","TA B 325","120","Select","Select",""],["","57896098110","ASPIRIN ","TAB 81MG EC","30","Select","Select",""],["","63868008210","PAIN ","TAB 325MG","120","Select","Select",""],["","00031223413","DIMETAPP ","LIQ COLD\/CGH","118","Select","Select",""],["","55111068305","IBU ","TAB 600MG","60","Select","Select",""],["","00536101810","TRAVEL ","CHW 25MG","20","Select","Select",""],["","57237007710","ONDANSETRON ","TAB 4MG ODT","10","Select","Select",""],["","76204060030","IPRATROPIUM\/ ","SOL ALBUTER","90","Select","Select",""],["","45802049326","AMMONIUM ","CRE 0.12","385","Select","Select",""],["","45802011222","MUPIROCIN ","OIN 0.02","22","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","",""],["N\/A","Select","","","","","Select","",""],["Yes","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":""}]}]}