{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"TONYA   M SAMPSON","gend":1,"add":"137 KEMPSVILLE ROAD","city":"CHESAPEAKE","state":"VA","zip":"23320-3715","dob":"1980-11-25","age":"","mstatus":"","insh":10165743,"cliId":"","pno":7575025711,"cno":7577907921,"email":"","ename":"","eno":"","pphy":"HUMADI, SAHIRA A","ppno":7574465955,"pcpadd":"1701 High St, Fl 1","pcpcity":"Portsmouth","pcpstate":"VA","pcpzip":237043103,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"TIDEWATER","aligned":"","ano":7577639814,"add2":"RM 205","add3":"","madd1":"137 KEMPSVILLE ROAD","madd2":"RM 205","madd3":"","mcity":"CHESAPEAKE","mstate":"VA","mzip":"23320-3715","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R10.9","R19.7","E86.0","N18.6","E10.22","Z53.21","R06.09","R07.9","D86.0","R73.9","Z87.891","I10","Z99.2","E10.9","Z86.718","D86.9","J45.50","R68.89","D50.9","D63.1","R06.02","E11.22","I12.0","R00.0","K21.9","Z79.4","Z79.899","E78.00","E87.70","N18.9","Z96.41","E10.10","E10.65","I95.9","R07.89","Z53.29","B00.9","E10.40","Z79.51","Z91.19","R11.2","R53.83","R11.10","R10.33","M79.10","E11.65","Z76.0","Z98.42","Z98.41","Z96.1","F31.9","E11.649","Z20.822","D86.89","E10.21","E11.42","E10.8","N25.81","R06.00","R53.1","R42","E78.5","E10.39","I34.0","I31.3","E87.79","A41.9","E87.5","Z86.39","I13.2","I50.9","R79.9","R79.89","Z87.09","Z53.20","R11.0","E89.2","R94.31","I50.41","I11.0","I42.8","R94.39","I42.9","E88.89","Z86.79","D64.9","L02.01","F20.9","E11.9","Z82.49","A49.02","L02.02","D84.9","J98.9","J84.10","I50.1","J44.9","Z86.19","Z79.52","L70.9","M25.512","E10.49","L84","R51.9","R52","J81.1","N26.1","R23.4","I87.1","Z12.4","Z11.3","R87.5","R14.0","Z87.2","L85.3","D22.9","Z86.59","D53.9","R25.2","T38.3X6A","E10.3299","E10.36","E10.42","N25.0","J45.909","Z23","L70.8","F31.30","E10.649","I50.30","E87.6","F17.210","B37.3","I12.9","Z20.828","Z82.3","I77.0"],"date":["2019-03-20","2021-05-13","2019-03-20","2021-05-15","2021-05-15","2019-03-20","2019-04-09","2019-12-29","2019-07-20","2019-04-11","2021-05-08","2021-04-27","2021-05-15","2019-07-22","2021-05-11","2021-05-15","2021-03-24","2021-02-25","2019-09-02","2021-05-08","2021-03-24","2021-02-09","2021-05-15","2021-02-09","2021-05-08","2021-05-15","2021-05-15","2021-05-08","2021-04-15","2019-12-19","2021-05-15","2020-10-29","2020-11-09","2020-04-25","2019-12-28","2019-12-28","2021-03-04","2021-02-06","2020-10-13","2020-10-29","2020-08-02","2020-08-02","2020-08-02","2020-08-02","2020-08-02","2020-08-02","2020-10-27","2020-11-14","2020-11-14","2020-11-14","2020-12-12","2021-02-09","2021-02-09","2021-04-15","2021-05-13","2021-05-13","2021-05-13","2020-10-29","2019-09-17","2019-03-30","2019-07-20","2021-04-13","2019-04-09","2019-04-10","2019-04-10","2019-05-01","2019-07-21","2019-10-15","2020-09-24","2019-09-20","2021-03-24","2019-10-07","2019-10-07","2019-10-07","2020-07-30","2021-05-13","2021-03-09","2019-04-10","2019-04-10","2019-04-10","2019-04-10","2019-04-11","2019-07-20","2019-10-11","2021-03-20","2021-04-15","2019-12-14","2020-10-20","2019-10-14","2021-03-20","2021-01-22","2021-01-22","2019-03-26","2019-05-21","2021-03-24","2019-05-21","2019-07-20","2020-03-26","2020-03-26","2020-06-02","2020-11-06","2020-11-09","2020-11-09","2021-02-09","2021-02-09","2019-04-09","2019-07-20","2020-03-12","2020-06-03","2021-04-13","2021-04-13","2021-04-13","2019-09-17","2019-10-28","2019-10-28","2019-10-28","2020-02-09","2020-05-30","2020-07-02","2020-10-29","2020-10-29","2020-10-29","2020-10-29","2020-10-29","2020-10-29","2020-10-29","2021-01-22","2021-03-24","2019-04-09","2019-07-20","2019-07-20","2019-07-20","2019-07-30","2019-11-09","2020-08-02","2021-01-19","2021-01-26"],"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":[["","00093729605","CARVEDILOL ","TAB 25MG","60","Select","Select",""],["","00054001825","PREDNISONE ","TAB 20MG","8","Select","Select",""],["","00597010061","SPIRIVA ","SPR 2.5MCG","12","Select","Select",""],["","00143980305","DOXYCYCL ","CAP 100MG","28","Select","Select",""],["","24979000912","NIFEDIPINE ","TAB 90MG ER","30","Select","Select",""],["","00093101042","MUPIROCIN ","OIN 0.02","22","Select","Select",""],["","00093317431","ALBUTEROL ","FAT E","17","Select","Select",""],["","00088221905","LANTUS ","INJ 100\/ML","6","Select","Select",""],["","00002822259","INSULIN ","INJ 100\/ML","12","Select","Select",""],["","69097081307","GABAPENTIN ","CAP 100MG","30","Select","Select",""],["","00169633910","NOVOLOG ","INJ FLEXPEN","15","Select","Select",""],["","29300022010","MONTELUKAST ","TAB 10MG","30","Select","Select",""],["","65862020399","LOSARTAN ","TAB 100MG","30","Select","Select",""],["","69097052444","DICLOFENAC ","GEL 0.01","100","Select","Select",""],["","52817033010","CYCLOBENZAPR ","TAB 5MG","10","Select","Select",""],["","49348097316","PAIN ","TAB 325MG","60","Select","Select",""],["","51672130104","AMMONIUM ","CRE 0.12","280","Select","Select",""],["","57599080000","FREESTY ","KIT 2 SENSOR","2","Select","Select",""],["","99073070805","FREESTYLE    MIS LITE","MIS LITE","1","Select","Select",""],["","68382004101","PROMETHAZINE ","TAB 25MG","10","Select","Select",""],["","08290320122","BD  PEN NEEDL","MIS 32GX4MM","100","Select","Select",""],["","59267100003","PFIZER ","INJ COVID-19","0.3","Select","Select",""],["","68180016613","VANCOMYCIN ","CAP 125MG","20","Select","Select",""],["","99073013001","FREESTYLE    MIS LANCETS","MIS LANCETS","100","Select","Select",""],["","08214114027","PEN  NEEDLES  ","MIS 32GX4MM","300","Select","Select",""],["","68462011944","FLUCONAZOLE ","TAB 150MG","2","Select","Select",""],["","99073070822","FREESTYLE    TES LITE","TES LITE","200","Select","Select",""],["","53885014301","ONETOUCH ","MIS LANCETS","100","Select","Select",""],["","00186037020","SYMBICORT ","AER 160-4.5","10.2","Select","Select",""],["","59310057922","PROAIR ","AER ","8.5","Select","Select",""],["","00002771559","BASAGLAR ","INJ 100UNIT","15","Select","Select",""],["","65862041901","SMZ-TMP ","TAB 400-80MG","11","Select","Select",""],["","00234057508","HIBICLENS ","LIQ 0.04","236","Select","Select",""],["","69543026010","VIRT-CAPS ","CAP ","30","Select","Select",""],["","00904188260","CALCIUM+D3 ","TAB 250-125","7","Select","Select",""],["","45802006405","TRIAMCINOLON ","CRE 0.001","454","Select","Select",""],["","00955105027","SEVELAMER ","TAB 800MG","90","Select","Select",""],["","00406012305","HYDROCO\/APAP ","5-325MG","10","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","",""],["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":""}]}]}