{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"SANDRA   A MELVIN","gend":1,"add":"904 WIDE ST","city":"NORFOLK","state":"VA","zip":"23504-9998","dob":"1955-01-11","age":"","mstatus":"","insh":"900036165*01","cliId":"8KA9QJ2TC49","pno":"757\/724-4462","cno":"757\/724-4462","email":"","ename":"","eno":"","pphy":"WHITE, DIANNA NP","ppno":"757\/623-0095","pcpadd":"SUITE 1 1401 TIDEWATER DRIVE","pcpcity":"NORFOLK","pcpstate":"VA","pcpzip":23504,"pcpcounty":"","pcpid":131851,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/623-1203","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z12.31","J45.20","J44.1","R91.1","M75.121","I10.","Z98.890","M75.51","M25.511","M25.611","M75.81","M47.816","M43.16","M75.101","Z01.812","Z01.810","M75.41","Z20.828","M75.111","M19.011","K80.20","K21.9","J44.9","J45.40","R06.02","J30.2","M54.5","R26.2","E78.5","I27.0","R30.0","M25.562","M51.36","M54.16","J98.9","R91.8","Z00.00","E03.9","Z11.4","E55.9","R73.03","M48.061","G89.18","N39.0","E07.9","R79.9","M15.9","J98.4","S43.421A","E78.00","M75.21","E66.9","Z68.31","Z79.899","Z88.1","Z88.5","Z88.8","J98.01","K44.9","M43.17","Z86.010","Z80.0","J41.0","I25.10","Z87.09","H25.813","H93.13","J30.9","H90.3","J31.0","Z12.39"],"date":["2021-09-11","2020-11-19","2021-08-26","2021-10-07","2020-11-20","2020-11-19","2020-11-20","2021-07-09","2021-02-23","2021-02-23","2021-03-02","2020-12-10","2020-03-09","2020-11-19","2020-11-16","2020-11-16","2020-11-19","2020-11-16","2020-11-19","2020-11-19","2021-07-09","2021-10-07","2021-10-07","2021-10-07","2021-05-26","2021-05-26","2020-12-10","2020-03-31","2020-11-19","2021-09-13","2020-08-10","2020-09-15","2020-01-13","2020-02-12","2020-05-19","2021-05-07","2021-01-19","2020-01-09","2020-01-09","2021-01-19","2020-01-09","2020-02-12","2020-11-19","2021-01-19","2021-01-19","2021-01-19","2020-03-11","2020-06-15","2020-04-20","2020-06-15","2020-10-03","2020-11-19","2020-11-19","2020-11-19","2020-11-19","2020-11-19","2020-11-19","2020-11-24","2021-05-07","2020-07-02","2020-09-22","2020-09-22","2021-04-26","2021-05-07","2021-05-07","2021-07-28","2021-08-09","2021-08-09","2021-08-09","2021-08-26","2021-09-11"],"priorHcc":[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":[["","51293081101","PHENAZOPYRID","TAB 200MG","6","Select","Select",""],["","68180046403","SIMVASTATIN","TAB 40MG","90","Select","Select",""],["","43386005019","GAVILYTE-N","SOL FLAV PK","4000","Select","Select",""],["","24208039915","IPRATROPIUM","SPR 0.0006","15","Select","Select",""],["","65862047099","LOSARTAN\/HCT","TAB 100-25","90","Select","Select",""],["","173072020","FLOVENT HFA","AER 220MCG","36","Select","Select",""],["","173086910","ANORO ELLIPT","AER 62.5-25","60","Select","Select",""],["","43598050930","ESOMEPRA MAG","CAP 20MG DR","18","Select","Select",""],["","60505095303","AZEL\/FLUTIC","SPR 137-50","23","Select","Select",""],["","172392670","DIAZEPAM","TAB 5MG","30","Select","Select",""],["","76204020060","ALBUTEROL","NEB 0.00083","180","Select","Select",""],["","69097094312","GABAPENTIN","CAP 300MG","90","Select","Select",""],["","31722072610","MONTELUKAST","TAB 10MG","21","Select","Select",""],["","781185220","AMOX\/K CLAV","TAB 875-125","14","Select","Select",""],["","59746067034","TIZANIDINE","CAP 2MG","90","Select","Select",""],["","406051201","OXYCOD\/APAP","TAB 5-325MG","-40","Select","Select",""],["","65162019050","NAPROXEN","TAB 500MG","16","Select","Select",""],["","172208380","HYDROCHLOROT","TAB 25MG","-90","Select","Select",""],["","406048410","APAP\/CODEINE","TAB 300-30MG","20","Select","Select",""],["","59762444002","METHYLPRED","TAB 4MG","-21","Select","Select",""],["","13668044101","CELECOXIB","CAP 100MG","60","Select","Select",""],["","68382024701","BENZONATATE","CAP 100MG","90","Select","Select",""],["","45802016000","DICLOFENAC","GEL 0.01","400","Select","Select",""],["","65862055990","PANTOPRAZOLE","TAB 20MG","90","Select","Select",""],["","70377002913","ATORVASTATIN","TAB 40MG","36","Select","Select",""],["","49281072010","FLUBLOK QUAD","INJ 2020-21","0","Select","Select",""],["","69097084615","CYCLOBENZAPR","TAB 10MG","12","Select","Select",""],["","65862047099","LOSARTAN POTASSIUM\/HYDROCHLOROTHIAZIDE","","30","Select","Select",""],["","31722072610","MONTELUKAST SODIUM ","","90","Select","Select",""],["","43598050930","ESOMEPRAZOLE MAGNESIUM","","90","Select","Select",""],["","59762444002","METHYLPREDNISOLONE DOSE PACK","","21","Select","Select",""],["","781185220","AMOXICILLIN\/CLAVULANATE POTASSIUM ","","14","Select","Select",""],["","172208380","HYDROCHLOROTHIAZIDE","","-90","Select","Select",""],["","173086910","ANORO ELLIPTA ","","60","Select","Select",""],["","93317431","ALBUTEROL SULFATE HFA","","17","Select","Select",""],["","76204020060","ALBUTEROL SULFATE","","-180","Select","Select",""],["","24208039915","IPRATROPIUM BROMIDE","","15","Select","Select",""],["","51293081101","PHENAZOPYRIDINE HCL","","6","Select","Select",""],["","59746067034","TIZANIDINE HYDROCHLORIDE","","90","Select","Select",""],["","69097084615","CYCLOBENZAPRINE HYDROCHLORIDE","","12","Select","Select",""],["","58657045001","PHENAZOPYRIDINE HYDROCHLORIDE","","21","Select","Select",""],["","45802016000","DICLOFENAC SODIUM","","400","Select","Select",""],["","43386005019","GAVILYTE-N\/FLAVOR PACK","","4000","Select","Select",""],["","406048410","ACETAMINOPHEN\/CODEINE","","30","Select","Select",""],["","406051201","OXYCODONE\/ACETAMINOPHEN","","-40","Select","Select",""],["","49281072010","FLUBLOK QUADRIVALENT 2020-2021","","0","Select","Select",""],["","60505095303","AZELASTINE HYDROCHLORIDE\/FLUTICASONE PROPIONATE","","23","Select","Select",""],["","13668044101","CELECOXIB ","","60","Select","Select",""],["","65862055990","PANTOPRAZOLE SODIUM","","90","Select","Select",""],["","70377002913","ATORVASTATIN CALCIUM ","","90","Select","Select",""],["","00173086910","ANORO ELLIPTA","","-180","Select","Select",""],["","31722072610","MONTELUKAST SODIUM","","21","Select","Select",""],["","00781185220","AMOXICILLIN\/CLAVULANATE POTASSIUM","","14","Select","Select",""],["","70377002913","ATORVASTATIN CALCIUM","","36","Select","Select",""],["","66993058597","FLUTICASONE PROPIONATE\/SALMETEROL DISKUS","250\/50","-60","Select","Select",""],["","49281012165","FLUZONE HIGH-DOSE PF 2021-2022","2021-22","1","Select","Select",""],["","00781185220","AMOXICILLIN\/CLAVULANATE POTASSIUM                                     ","TAB 875-125","14","Select","Select",""],["","76204020060","ALBUTEROL SULFATE                                                     ","NEB 0.00083","-180","Select","Select",""],["","24208039915","IPRATROPIUM BROMIDE                                                   ","SPR 0.0006","15","Select","Select",""],["","00173086910","ANORO ELLIPTA                                                         ","AER 62.5-25","60","Select","Select",""],["","59746067034","TIZANIDINE HYDROCHLORIDE                                              ","CAP 2MG","90","Select","Select",""],["","68180046403","SIMVASTATIN                                                           ","TAB 40MG","90","Select","Select",""],["","31722072610","MONTELUKAST SODIUM                                                    ","TAB 10MG","90","Select","Select",""],["","00173072020","FLOVENT HFA                                                           ","AER 220MCG","12","Select","Select",""],["","65862047099","LOSARTAN POTASSIUM\/HYDROCHLOROTHIAZIDE                                ","TAB 100-25","30","Select","Select",""],["","43598050930","ESOMEPRAZOLE MAGNESIUM                                                ","CAP 20MG DR","30","Select","Select",""],["","00172208380","HYDROCHLOROTHIAZIDE                                                   ","TAB 25MG","90","Select","Select",""],["","45802008801","ALBUTEROL SULFATE HFA                                                 ","AER HFA","8","Select","Select",""],["","58657045001","PHENAZOPYRIDINE HYDROCHLORIDE                                         ","TAB 100MG","21","Select","Select",""],["","00406048410","ACETAMINOPHEN\/CODEINE                                                 ","TAB 300-30MG","20","Select","Select",""],["","58657045101","PHENAZOPYRIDINE HCL                                                   ","TAB 200MG","6","Select","Select",""],["","00172392670","DIAZEPAM                                                              ","TAB 5MG","-30","Select","Select",""],["","59762444002","METHYLPREDNISOLONE DOSE PACK                                          ","TAB 4MG","21","Select","Select",""],["","69097094312","GABAPENTIN                                                            ","CAP 300MG","90","Select","Select",""],["","69097084615","CYCLOBENZAPRINE HYDROCHLORIDE                                         ","TAB 10MG","12","Select","Select",""],["","45802016000","DICLOFENAC SODIUM                                                     ","GEL 0.01","400","Select","Select",""],["","68382024701","BENZONATATE                                                           ","CAP 100MG","90","Select","Select",""],["","43386005019","GAVILYTE-N\/FLAVOR PACK                                                ","SOL FLAV PK","4000","Select","Select",""],["","60505095303","AZELASTINE HYDROCHLORIDE\/FLUTICASONE PROPIONATE                       ","SPR 137-50","23","Select","Select",""],["","49281072010","FLUBLOK QUADRIVALENT 2020-2021                                        ","INJ 2020-21","0","Select","Select",""],["","65162019050","NAPROXEN                                                              ","TAB 500MG","16","Select","Select",""],["","00406051201","OXYCODONE\/ACETAMINOPHEN                                               ","TAB 5-325MG","-40","Select","Select",""],["","13668044101","CELECOXIB                                                             ","CAP 100MG","60","Select","Select",""],["","70377002913","ATORVASTATIN CALCIUM                                                  ","TAB 40MG","36","Select","Select",""],["","65862055990","PANTOPRAZOLE SODIUM                                                   ","TAB 20MG","90","Select","Select",""],["","66993058597","FLUTICASONE PROPIONATE\/SALMETEROL DISKUS                              ","AER 250\/50","60","Select","Select",""],["","60505004101","ETODOLAC                                                              ","TAB 400MG","60","Select","Select",""],["","70010077005","METHOCARBAMOL                                                         ","TAB 750MG","30","Select","Select",""],["","49281012165","FLUZONE HIGH-DOSE PF 2021-2022                                        ","INJ 2021-22","1","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","",""],["No","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["No","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":""}]}]}