{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"EVE HINER","gend":1,"add":"813 FISHERS CIRCLE                                          ","city":"STAUNTON                      ","state":"VA","zip":"24401-4847","dob":"1999-08-18","age":"","mstatus":"","insh":10052418,"cliId":"","pno":5405690809,"cno":5405690809,"email":"","ename":"","eno":"","pphy":"FARLEY, BENJAMIN GATES                                      ","ppno":"","pcpadd":"42 Lambert St,Ste E","pcpcity":"Staunton                      ","pcpstate":"VA","pcpzip":244012437,"pcpcounty":"","pcpid":"P0112778","pcpname":"STAUNTON MEDICAL ASSOCIATES","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"813 FISHERS CIRCLE                                          ","madd2":"                                                            ","madd3":"","mcity":"STAUNTON                      ","mstate":"VA","mzip":"24401-4847","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["B37.3","N39.0","N89.8","Z30.42","F33.2","F41.9","F32.2","F71","Z11.3","N76.0","Z01.419","D68.0","M54.6","R07.9","M25.511","Z71.6","Z72.0","Z88.6","L25.9","J02.9","R07.0","J20.9","R05","R09.81","Z88.8","M79.672","S93.602A","W19.XXXA","Z32.02","N94.10","R23.9","Z72.51","R10.2","R10.31","Z79.899","Z20.828","R07.89","B88.8","W57.XXXA","Z11.8","S80.861A","B96.89","Q64.9","F41.1","F41.0","A08.4","N93.9","M25.541","S66.116A","X50.0XXA","Z20.818","S20.462A","S20.461A","R30.9","R10.9","Z86.39","Z87.898","Z87.42","D69.6","Z30.09","Z91.89","Z55.0","Z91.19","Z87.891","Z59.8","R50.9","Z20.822","M79.604","I82.811","M79.661","Z79.52","M25.571","I80.01","Z59.89","M25.561","M79.651","Z51.81","Z30.011","Z78.9","Z79.01","I49.9","D68.318","I80.9","K21.9","Z65.9","Z00.00","I82.812"],"date":["2021-04-02","2019-01-11","2021-01-08","2019-03-29","2019-09-12","2021-11-05","2019-09-09","2019-09-09","2021-04-02","2020-12-04","2020-11-09","2021-11-05","2019-12-23","2019-12-22","2019-12-22","2019-12-22","2020-06-30","2021-10-14","2019-12-30","2021-11-07","2020-02-01","2020-02-08","2021-08-26","2020-02-08","2021-10-14","2020-02-13","2020-02-13","2020-02-13","2021-03-01","2020-02-28","2020-03-07","2020-04-16","2020-06-07","2020-06-08","2021-09-24","2021-08-26","2020-06-30","2020-10-16","2021-06-07","2020-11-09","2020-11-22","2020-12-04","2021-01-08","2021-01-14","2021-01-14","2021-02-19","2021-03-01","2021-03-20","2021-03-20","2021-03-20","2021-05-11","2021-06-07","2021-06-07","2021-06-22","2021-06-23","2021-07-13","2021-07-13","2021-11-05","2021-10-26","2021-11-05","2021-11-05","2021-10-01","2021-10-26","2021-11-05","2021-07-13","2021-08-26","2021-11-07","2021-11-05","2021-11-05","2021-10-14","2021-09-24","2021-09-24","2021-09-29","2021-10-01","2021-10-14","2021-10-15","2021-10-15","2021-10-15","2021-10-26","2021-10-15","2021-10-01","2021-10-01","2021-10-01","2021-10-01","2021-11-05","2021-11-05","2021-11-05"],"priorHcc":["","","","","",null,"","","","","",null,"","","","","","","",null,"","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",null,null,null,null,"",null,null,"","",null,null,null,"","","","","","","","","",null,"",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":[]},{"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":[["","50383077504","LIDOCAINE","2% VISC","100","Select","Select",""],["","63824017165","DELSYM","30MG\/5ML","100","Select","Select",""],["","00378827052","ALBUTEROL","0.08%","75","Select","Select",""],["","68180086473","BLISOVI","FE 1\/20","28","Select","Select",""],["","00555901658","SPRINTEC","28 DAY","28","Select","Select",""],["","51862007206","AZURETTE","28 DAY","84","Select","Select",""],["","55111014512","FLUCONAZOLE","150MG","1","Select","Select",""],["","17478044708","AMINOCAPROIC","0.25\/ML","236.5","Select","Select",""],["","50111033401","METRONIDAZOL","500MG","14","Select","Select",""],["","53489011905","DOXYCYCL","100MG","20","Select","Select",""],["","49411005208","AMICAR","0.25\/ML","236.5","Select","Select",""],["","00093101042","MUPIROCIN","2%","22","Select","Select",""],["","00904772524","ANTI-DIARRHE","2MG","30","Select","Select",""],["","10702001150","HYDROXYZ","25MG","6","Select","Select",""],["","68462015713","ONDANSETRON","4MG ODT","30","Select","Select",""],["","00054327099","FLUTICASONE","50MCG","16","Select","Select",""],["","16571040250","CETIRIZINE","10MG","30","Select","Select",""],["","57237016199","OMEPRAZOLE","20MG","60","Select","Select",""],["","49483060250","IBUPROFEN","400MG","14","Select","Select",""],["","16729020201","BUSPIRONE","10MG","90","Select","Select",""],["","59746017509","PREDNISONE","20MG","10","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","15","Select","Select",""],["","33342032915","TRIAMCINOLON","0.10%","30","Select","Select",""],["","50383077504","LIDOCAINE ","SOL 2% VISC","100","Select","Select",""],["","63824017165","DELSYM ","SUS 30MG\/5ML","100","Select","Select",""],["","00378827052","ALBUTEROL ","NEB 0.00083","75","Select","Select",""],["","68180086473","BLISOVI ","TAB FE 1\/20","28","Select","Select",""],["","00555901658","SPRINTEC ","TAB 28 DAY","28","Select","Select",""],["","51862007206","AZURETTE ","TAB 28 DAY","84","Select","Select",""],["","55111014512","FLUCONAZOLE ","TAB 150MG","1","Select","Select",""],["","00003089321","ELIQUIS ","TAB 2.5MG","42","Select","Select",""],["","68462030529","NORETHINDRON ","TAB 0.35MG","28","Select","Select",""],["","49483060250","IBUPROFEN ","TAB 400MG","14","Select","Select",""],["","17478044708","AMINOCAPROIC ","SOL 0.25\/ML","236.5","Select","Select",""],["","50111033401","METRONIDAZOL ","TAB 500MG","14","Select","Select",""],["","53489011905","DOXYCYCL ","CAP 100MG","20","Select","Select",""],["","49411005208","AMICAR ","SOL 0.25\/ML","236.5","Select","Select",""],["","00093101042","MUPIROCIN ","OIN 0.02","22","Select","Select",""],["","00904772524","ANTI-DIARRHE ","TAB 2MG","30","Select","Select",""],["","57237016199","OMEPRAZOLE ","CAP 20MG","7","Select","Select",""],["","10702001150","HYDROXYZ ","TAB 25MG","6","Select","Select",""],["","68462015713","ONDANSETRON ","TAB 4MG ODT","30","Select","Select",""],["","00054327099","FLUTICASONE ","SPR 50MCG","16","Select","Select",""],["","16571040250","CETIRIZINE ","TAB 10MG","30","Select","Select",""],["","16729020201","BUSPIRONE ","TAB 10MG","90","Select","Select",""],["","59746017509","PREDNISONE ","TAB 20MG","10","Select","Select",""],["","69097083305","SERTRALINE ","TAB 25MG","30","Select","Select",""],["","68180012202","CEPHALEXIN ","CAP 500MG","15","Select","Select",""],["","33342032915","TRIAMCINOLON ","CRE 0.001","30","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":""}]}]}