{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"VICKIE   C JUSTICE","gend":1,"add":"GUARDIAN ASSISTED LIVING                                    ","city":"CASTLEWOOD                    ","state":"VA","zip":"24224-6147","dob":"1959-01-10","age":"","mstatus":"","insh":10060187,"cliId":"","pno":2767949569,"cno":"","email":"","ename":"","eno":"","pphy":"BLACKWELL, KELLIE M                                         ","ppno":"","pcpadd":"24530 Falcon Place Blvd Ste 201,Ste 100","pcpcity":"Abingdon                      ","pcpstate":"VA","pcpzip":242117665,"pcpcounty":"","pcpid":"P9059204","pcpname":"WELLMONT CVA HEART INSTITUTE","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"SOUTHWEST","aligned":"","ano":"","add2":"99 CULBERTSON LANE                                          ","add3":"","madd1":"GUARDIAN ASSISTED LIVING                                    ","madd2":"99 CULBERTSON LANE                                          ","madd3":"","mcity":"CASTLEWOOD                    ","mstate":"VA","mzip":"24224-6147","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F20.9","F33.1","F70","G47.09","R68.89","R05","F20.3","F41.1","J30.9","Z72.0","F20.89","Z13.220","T43.595D","J30.89","F51.04","F17.210","Z51.81","Z12.31","Z12.4","Z12.11","Z12.2","J20.9","J41.0","F15.20","R21"],"date":["2021-09-16","2021-09-16","2021-09-16","2019-06-06","2020-03-12","2019-05-02","2020-11-03","2020-09-03","2019-06-06","2019-06-06","2019-07-11","2019-07-11","2019-08-07","2020-09-03","2020-09-03","2020-09-03","2021-04-06","2020-03-05","2020-03-05","2020-06-04","2020-03-05","2020-03-19","2020-09-03","2020-06-04","2020-07-09"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","",""]}},{"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":[["","68001018203","QUETIAPINE","200MG","56","Select","Select",""],["","00603243832","BENZTROPINE","1MG","28","Select","Select",""],["","43598081115","CETIRIZINE","10MG","28","Select","Select",""],["","00185067405","HYDROXYZ","25MG","56","Select","Select",""],["","87701040813","MELATONIN","3MG","28","Select","Select",""],["","67457035959","FLUPHENAZ","25MG\/ML","5","Select","Select",""],["","45802006435","TRIAMCINOLON","0.10%","30","Select","Select",""],["","67877032105","IBUPROFEN","800MG","30","Select","Select",""],["","65862064169","AZITHROMYCIN","250MG","6","Select","Select",""],["","00456315467","AEROCHAMBER","PLUS","1","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","00603533932","PREDNISONE","20MG","10","Select","Select",""],["","24385057826","GNP","DM COUGH","118","Select","Select",""],["","45802043401","CLOTRIMAZOLE","1%","30","Select","Select",""],["","68001018203","QUETIAPINE ","TAB 200MG","56","Select","Select",""],["","00603243832","BENZTROPINE ","TAB 1MG","28","Select","Select",""],["","43598081115","CETIRIZINE ","TAB 10MG","28","Select","Select",""],["","00185067405","HYDROXYZ ","CAP 25MG","56","Select","Select",""],["","87701040813","MELATONIN ","TAB 3MG","28","Select","Select",""],["","67457035959","FLUPHENAZ ","INJ 25MG\/ML","5","Select","Select",""],["","45802006435","TRIAMCINOLON ","CRE 0.001","30","Select","Select",""],["","67877032105","IBUPROFEN ","TAB 800MG","30","Select","Select",""],["","65862064169","AZITHROMYCIN ","TAB 250MG","6","Select","Select",""],["","00456315467","AEROCHAMBER ","MIS PLUS","1","Select","Select",""],["","66993001968","ALBUTEROL ","AER HFA","18","Select","Select",""],["","00603533932","PREDNISONE ","TAB 20MG","10","Select","Select",""],["","24385057826","GNP ","LIQ DM COUGH","118","Select","Select",""],["","45802043401","CLOTRIMAZOLE ","CRE 0.01","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","",""],["Yes","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["No","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":""}]}]}