{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MOLLIE COBB","gend":1,"add":"71 LEA DRIVE","city":"FISHERSVILLE","state":"VA","zip":"22939-2228","dob":"1983-10-05","age":"","mstatus":"","insh":6948458,"cliId":"","pno":5408368969,"cno":5408368969,"email":"","ename":"","eno":"","pphy":"HOSTETTER, SAMUEL A","ppno":5403373710,"pcpadd":"24 Gloucester Rd, ","pcpcity":"Stuarts Draft","pcpstate":"VA","pcpzip":244773321,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP","program":"MEDICAID","lob":"VPM4","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"71 LEA DRIVE","madd2":"                                                            ","madd3":"","mcity":"FISHERSVILLE","mstate":"VA","mzip":"22939-2228","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["L03.115","Z20.828","R11.0","S32.19XA","S32.82XA","M25.522","W19.XXXA","S06.5X9A","S32.119A","V47.5XXA","Y92.410","K72.00","S32.402A","S22.43XA","S22.22XA","S27.0XXA","S27.321A","E87.2","Z87.891","D72.829","R33.9","R51.9","V87.7XXA","T14.90XA","K76.0","R16.1","K57.30","M25.78","M51.26","M51.27","S39.92XA","S29.9XXA","S32.10XA","S32.599S","S32.592A","M79.642","S32.2XXA","S39.82XA","W17.89XA","Y93.89","Y92.008","M54.5","M54.6","R41.0","Z72.0","M54.2","R07.9","V89.2XXA","R41.82","R10.9","M54.9","S32.9XXA","S09.90XA","S19.9XXA","I62.00","Z20.822","S22.20XA","S22.42XA","J98.11","F15.20","R17","S39.93XA","R10.30","I95.9","S22.31XA","S32.509A","S30.0XXA","S32.602A","S79.912A","K80.20","F15.10"],"date":["2020-08-23","2020-10-28","2020-10-28","2020-11-13","2020-11-12","2020-01-05","2020-01-05","2020-11-12","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-12","2020-11-11","2020-11-12","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-13","2020-11-13","2020-01-05","2020-01-05","2020-01-05","2020-01-05","2020-01-05","2020-01-05","2020-01-05","2020-11-11","2020-11-11","2020-11-12","2020-11-12","2020-11-13","2020-01-05","2020-01-05","2020-01-05","2020-01-05","2020-01-05","2020-01-05","2020-01-05","2020-01-05","2020-01-05","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-01-05","2020-11-11","2020-11-12","2021-02-15","2020-11-11","2020-11-12","2020-11-12","2020-04-29","2020-11-12","2020-11-11","2020-01-05","2020-01-05","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-12","2021-03-03"],"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":[["","00143314250","DOXYCYCL ","CAP 100MG","20","Select","Select",""],["","67877032105","IBUPROFEN ","TAB 800MG","30","Select","Select",""],["","65862007701","CIPROFLOXACN ","TAB 500MG","20","Select","Select",""],["","71930001752","ONDANSETRON ","TAB 4MG","20","Select","Select",""],["","00904645780","DOK ","CAP 100MG","10","Select","Select",""],["","00406055201","OXYCODONE ","TAB 5MG","15","Select","Select",""],["","53746010901","HYDROCO\/APAP ","TAB 5-325MG","10","Select","Select",""],["","00904671980","ACETAMINOPHEN ","TA B 325","30","Select","Select",""],["","68180011302","LEVETIRACETA ","TAB 500MG","6","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","",""],["N\/A","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":""}]}]}