{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ROSA   M ROSE","gend":1,"add":"227 FLOYD AVE","city":"RICHLANDS","state":"VA","zip":"24641-9998","dob":"1966-01-13","age":"","mstatus":"","insh":"900036065*01","cliId":"2QA0X35CT43","pno":"276\/245-7687","cno":"276\/245-7687","email":"","ename":"","eno":"","pphy":"","ppno":"","pcpadd":"","pcpcity":"","pcpstate":"","pcpzip":"","pcpcounty":"","pcpid":"","pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"SOUTHWEST","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["J45.40","M99.81","M54.2","G62.9","M54.16","J01.01","R39.9","R07.2","K21.9","R20.0","Z12.11","R05.","E11.69","I10.","M81.0","Z12.31","R15.9","R31.9","E11.9","R30.0","Z23.","G47.33","R33.9","N39.46","D50.8","J01.00","M50.30","N39.0","J32.0","Z79.899","E66.9","Z68.36","R06.02","Z87.19","L29.9","Z03.818","R53.1","B30.1","J01.10","H01.002","H01.005","F51.01","E78.2","K90.0","K62.3","H25.813","E78.5","G47.19","F41.9","J06.9","J32.9","J45.20","Z68.37","M50.31","K12.1","Z68.30","R13.10","K62.5","R39.15"],"date":["2021-01-22","2020-03-23","2021-06-30","2019-11-20","2021-05-17","2019-10-21","2019-12-18","2019-10-21","2021-11-04","2019-11-13","2021-05-23","2020-02-13","2020-04-24","2021-11-05","2020-05-26","2020-05-26","2020-10-16","2020-10-16","2021-09-16","2021-07-29","2020-10-29","2021-11-05","2021-09-22","2021-03-24","2019-12-18","2020-02-07","2020-06-04","2021-07-29","2019-11-20","2021-11-05","2021-11-05","2021-03-08","2021-03-19","2020-08-03","2020-11-24","2020-12-31","2021-01-19","2021-01-29","2021-02-19","2021-05-20","2021-05-20","2019-12-18","2020-08-03","2021-11-12","2019-12-18","2021-08-12","2021-05-17","2021-01-22","2021-05-17","2021-03-19","2021-05-17","2021-02-26","2021-05-03","2021-08-12","2021-02-19","2021-11-05","2021-11-04","2021-11-04","2021-09-22"],"priorHcc":["","","","","","","","",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":[["","16729011910","MONTELUKAST","TAB 10MG","30","Select","Select",""],["","378345823","AZEL\/FLUTIC","SPR 137-50","23","Select","Select",""],["","54327099","FLUTICASONE","SPR 50MCG","16","Select","Select",""],["","17478071710","KETOTIF FUM","DRO 0.025%OP","5","Select","Select",""],["","47781022905","OXYCOD\/APAP","TAB 7.5-325","60","Select","Select",""],["","62559043130","HYDROCORTISO","CRE 0.025","30","Select","Select",""],["","487950125","ALBUTEROL","NEB 0.00083","300","Select","Select",""],["","37024523","DYMISTA","SPR 137-50","23","Select","Select",""],["","597014030","TRADJENTA","TAB 5MG","30","Select","Select",""],["","65862032904","ALENDRONATE","TAB 70MG","4","Select","Select",""],["","67777012114","ALCOHOL PREP","PAD ","100","Select","Select",""],["","53885013610","ONETOUCH","MIS LANCETS","100","Select","Select",""],["","55111078430","FEXOFENADINE","TAB 180MG","30","Select","Select",""],["","93031101","LOPERAMIDE","CAP 2MG","30","Select","Select",""],["","68180071160","CEFDINIR","CAP 300MG","20","Select","Select",""],["","65862001099","METFORMIN","TAB 1000MG","60","Select","Select",""],["","60505257909","ATORVASTATIN","TAB 20MG","30","Select","Select",""],["","27241009990","DULOXETINE","CAP 60MG","30","Select","Select",""],["","50111064802","FLUOXETINE","CAP 20MG","30","Select","Select",""],["","536329210","VITAMIN C","TAB 500MG","30","Select","Select",""],["","57237003105","AMOXICILLIN","CAP 500MG","30","Select","Select",""],["","185094098","CHOLESTYRAM","POW 4GM","60","Select","Select",""],["","61442012201","FAMOTIDINE","TAB 40MG","30","Select","Select",""],["","67877021905","CEPHALEXIN","CAP 500MG","20","Select","Select",""],["","42571016242","AMOX\/K CLAV","TAB 875-125","20","Select","Select",""],["","591544301","PREDNISONE","TAB 20MG","10","Select","Select",""],["","378699052",""," ","300","Select","Select",""],["","60505083305","AZELASTINE","SPR 0.001","30","Select","Select",""],["","64679096104","AZITHROMYCIN","TAB 250MG","6","Select","Select",""],["","65862059805","TAMSULOSIN","CAP 0.4MG","90","Select","Select",""],["","24208029525","TOBRA\/DEXAME","SUS 0.3-0.1%","2","Select","Select",""],["","527512170","NYSTATIN","SUS 100000","480","Select","Select",""],["","67405065105","DOXYCYCL HYC","CAP 100MG","14","Select","Select",""],["","456120230","LINZESS","CAP 290MCG","30","Select","Select",""],["","43598051030","ESOMEPRA MAG","CAP 40MG DR","30","Select","Select",""],["","45963055550","GABAPENTIN","CAP 100MG","90","Select","Select",""],["","61971012005","SMZ\/TMP DS","TAB 800-160","14","Select","Select",""],["","59651017301","DOXEPIN HCL","CAP 10MG","30","Select","Select",""],["","57237000511","FLUCONAZOLE","TAB 150MG","5","Select","Select",""],["","37205025172","SENNA PLUS","TAB 8.6-50MG","60","Select","Select",""],["","65064835","TOBRADEX","OIN 0.3-0.1%","4","Select","Select",""],["","24208083060","NEO\/POLY\/DEX","SUS 0.1% OP","5","Select","Select",""],["","47781030301","NITROFURANTN","CAP 100MG","14","Select","Select",""],["","62559043130","HYDROCORTISONE","","30","Select","Select",""],["","47781022905","OXYCODONE\/ACETAMINOPHEN","","90","Select","Select",""],["","50111064802","FLUOXETINE HCL","","30","Select","Select",""],["","16729011910","MONTELUKAST SODIUM ","","30","Select","Select",""],["","456120230","LINZESS ","","30","Select","Select",""],["","67777012114","ALCOHOL PREP PADS","","100","Select","Select",""],["","42571016242","AMOXICILLIN\/CLAVULANATE POTASSIUM ","","10","Select","Select",""],["","53885027150","ONETOUCH VERIO TEST STRIPS","","100","Select","Select",""],["","487950125","ALBUTEROL SULFATE","","300","Select","Select",""],["","60505257909","ATORVASTATIN CALCIUM ","","30","Select","Select",""],["","65862000805","METFORMIN HYDROCHLORIDE","","60","Select","Select",""],["","53885013610","ONETOUCH DELICA LANCETS EXTRA FINE 33G","","100","Select","Select",""],["","27241009990","DULOXETINE HYDROCHLORIDE","","30","Select","Select",""],["","60505083305","AZELASTINE HYDROCHLORIDE","","30","Select","Select",""],["","43598051030","ESOMEPRAZOLE MAGNESIUM","","30","Select","Select",""],["","93031101","LOPERAMIDE HCL","","30","Select","Select",""],["","67405065105","DOXYCYCLINE HYCLATE","","14","Select","Select",""],["","60505299603","DULOXETINE HCL","","30","Select","Select",""],["","65862032904","ALENDRONATE SODIUM ","","4","Select","Select",""],["","536329210","VITAMIN C ","","30","Select","Select",""],["","17478071710","KETOTIFEN FUMARATE ","","5","Select","Select",""],["","61971012005","SULFAMETHOXAZOLE\/TRIMETHOPRIM DS","","14","Select","Select",""],["","55111078430","FEXOFENADINE HYDROCHLORIDE","","30","Select","Select",""],["","47781030301","NITROFURANTOIN MONOHYDRATE\/MACROCRYSTALS","","14","Select","Select",""],["","54327099","FLUTICASONE PROPIONATE","","16","Select","Select",""],["","378345823","AZELASTINE HYDROCHLORIDE\/FLUTICASONE PROPIONATE","","23","Select","Select",""],["","37024523","DYMISTA ","","23","Select","Select",""],["","59651017301","DOXEPIN HYDROCHLORIDE","","30","Select","Select",""],["","24208029525","TOBRAMYCIN\/DEXAMETHASONE","","2","Select","Select",""],["","37205025172","SENNA-PLUS","","60","Select","Select",""],["","597014030","TRADJENTA ","","30","Select","Select",""],["","68382052860","CHOLESTYRAMINE","","60","Select","Select",""],["","24208083060","NEOMYCIN\/POLYMYXIN\/DEXAMETHASONE","","5","Select","Select",""],["","65862059805","TAMSULOSIN HYDROCHLORIDE","","90","Select","Select",""],["","93317431","ALBUTEROL SULFATE HFA","","8","Select","Select",""],["","24208091055","ERYTHROMYCIN","","4","Select","Select",""],["","57237007530","ONDANSETRON HYDROCHLORIDE ","","30","Select","Select",""],["","16729011910","MONTELUKAST SODIUM","","30","Select","Select",""],["","60505257909","ATORVASTATIN CALCIUM","","30","Select","Select",""],["","42571016242","AMOXICILLIN\/CLAVULANATE POTASSIUM","","10","Select","Select",""],["","65862032904","ALENDRONATE SODIUM","","4","Select","Select",""],["","17478071710","KETOTIFEN FUMARATE","","5","Select","Select",""],["","57237007530","ONDANSETRON HYDROCHLORIDE","","30","Select","Select",""],["","51672128103","DESONIDE","","360","Select","Select",""],["","50742031160","CLOBETASOL PROPIONATE EMOLLIENT","","-180","Select","Select",""],["","71800000960","DIFLORASONE DIACETATE","","360","Select","Select",""],["","52565008260","CLOBETASOL PROPIONATE","","180","Select","Select",""],["","55111012705","CIPROFLOXACIN HYDROCHLORIDE","500MG","20","Select","Select",""],["","53885027150","ONETOUCH VERIO TEST STRIPS                                            ","TES VERIO","100","Select","Select",""],["","61442012201","FAMOTIDINE                                                            ","TAB 40MG","30","Select","Select",""],["","60505299603","DULOXETINE HCL                                                        ","CAP 30MG","30","Select","Select",""],["","47781022905","OXYCODONE\/ACETAMINOPHEN                                               ","TAB 7.5-325","60","Select","Select",""],["","60505257909","ATORVASTATIN CALCIUM                                                  ","TAB 20MG","30","Select","Select",""],["","00093031101","LOPERAMIDE HCL                                                        ","CAP 2MG","30","Select","Select",""],["","65862001099","METFORMIN HYDROCHLORIDE                                               ","TAB 1000MG","60","Select","Select",""],["","57237003105","AMOXICILLIN                                                           ","CAP 500MG","30","Select","Select",""],["","00487950125","ALBUTEROL SULFATE                                                     ","NEB 0.00083","300","Select","Select",""],["","50111064802","FLUOXETINE HCL                                                        ","CAP 20MG","30","Select","Select",""],["","27241009990","DULOXETINE HYDROCHLORIDE                                              ","CAP 60MG","30","Select","Select",""],["","00591544301","PREDNISONE                                                            ","TAB 20MG","10","Select","Select",""],["","16729011910","MONTELUKAST SODIUM                                                    ","TAB 10MG","30","Select","Select",""],["","62559043130","HYDROCORTISONE                                                        ","CRE 0.025","30","Select","Select",""],["","67777012114","ALCOHOL PREP PADS                                                     ","PAD ","100","Select","Select",""],["","65862032904","ALENDRONATE SODIUM                                                    ","TAB 70MG","4","Select","Select",""],["","00456120230","LINZESS                                                               ","CAP 290MCG","30","Select","Select",""],["","55111078430","FEXOFENADINE HYDROCHLORIDE                                            ","TAB 180MG","30","Select","Select",""],["","17478071710","KETOTIFEN FUMARATE                                                    ","DRO 0.025%OP","5","Select","Select",""],["","00054327099","FLUTICASONE PROPIONATE                                                ","SPR 50MCG","16","Select","Select",""],["","67405065105","DOXYCYCLINE HYCLATE                                                   ","CAP 100MG","14","Select","Select",""],["","53885013610","ONETOUCH DELICA LANCETS EXTRA FINE 33G                                ","MIS LANCETS","100","Select","Select",""],["","00536329210","VITAMIN C                                                             ","TAB 500MG","30","Select","Select",""],["","59651017301","DOXEPIN HYDROCHLORIDE                                                 ","CAP 10MG","30","Select","Select",""],["","68180071160","CEFDINIR                                                              ","CAP 300MG","20","Select","Select",""],["","61971012005","SULFAMETHOXAZOLE\/TRIMETHOPRIM DS                                      ","TAB 800-160","14","Select","Select",""],["","47781030301","NITROFURANTOIN MONOHYDRATE\/MACROCRYSTALS                              ","CAP 100MG","14","Select","Select",""],["","37205025172","SENNA-PLUS                                                            ","TAB 8.6-50MG","60","Select","Select",""],["","68180012101","CEPHALEXIN                                                            ","CAP 250MG","30","Select","Select",""],["","00378345823","AZELASTINE HYDROCHLORIDE\/FLUTICASONE PROPIONATE                       ","SPR 137-50","23","Select","Select",""],["","57237000511","FLUCONAZOLE                                                           ","TAB 150MG","5","Select","Select",""],["","00037024523","DYMISTA                                                               ","SPR 137-50","-23","Select","Select",""],["","24208029505","TOBRAMYCIN\/DEXAMETHASONE                                              ","SUS 0.3-0.1%","5","Select","Select",""],["","59762306001","AZITHROMYCIN                                                          ","TAB 250MG","6","Select","Select",""],["","24208083060","NEOMYCIN\/POLYMYXIN\/DEXAMETHASONE                                      ","SUS 0.1% OP","5","Select","Select",""],["","00093227434","AMOXICILLIN\/CLAVULANATE POTASSIUM                                     ","TAB 500-125","30","Select","Select",""],["","00597014030","TRADJENTA                                                             ","TAB 5MG","30","Select","Select",""],["","00065064835","TOBRADEX                                                              ","OIN 0.3-0.1%","4","Select","Select",""],["","00527512170","NYSTATIN                                                              ","SUS 100000","480","Select","Select",""],["","68382052860","CHOLESTYRAMINE                                                        ","POW 4GM","60","Select","Select",""],["","00093317431","ALBUTEROL SULFATE HFA                                                 ","AER HFA","8","Select","Select",""],["","65862059805","TAMSULOSIN HYDROCHLORIDE                                              ","CAP 0.4MG","90","Select","Select",""],["","51672128103","DESONIDE                                                              ","OIN 0.0005","360","Select","Select",""],["","24208091055","ERYTHROMYCIN                                                          ","OIN 5MG\/GM","4","Select","Select",""],["","57237007530","ONDANSETRON HYDROCHLORIDE                                             ","TAB 4MG","30","Select","Select",""],["","0","                                                                      "," ","360","Select","Select",""],["","52565008260","CLOBETASOL PROPIONATE                                                 ","GEL 0.0005","-180","Select","Select",""],["","50742031160","CLOBETASOL PROPIONATE EMOLLIENT                                       ","CRE 0.0005","-180","Select","Select",""],["","10572010101","PEG-3350\/ELECTROLYTES                                                 ","SOL ELECTROL","4000","Select","Select",""],["","55111012705","CIPROFLOXACIN HYDROCHLORIDE                                           ","TAB 500MG","20","Select","Select",""],["","71800000960","DIFLORASONE DIACETATE                                                 ","OIN 0.0005","360","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","",""],["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["N\/A","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":""}]}]}