{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARJANI   K SIVELLS","gend":1,"add":"6243 DREW DR","city":"VIRGINIA BEACH","state":"VA","zip":"23464-9998","dob":"1974-08-16","age":"","mstatus":"","insh":"900037046*01","cliId":"8P60EY7DF10","pno":"757\/233-4047","cno":"757\/233-4047","email":"","ename":"","eno":"","pphy":"BEVERLY, VERNIS MD","ppno":"757\/484-2001","pcpadd":"STE A 3800 POPLAR HILL RD","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":23321,"pcpcounty":"","pcpid":128565,"pcpname":"Adult and Pediatric Medical Associates","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/484-2182","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R15.9","N32.81","Z99.3","G80.0","G47.33","C69.62","C71.9","G80.9","M89.8X8","R93.0","D32.9","G47.30","G40.909","Z80.41","Z79.51","Z79.899","Z88.0","G40.009","R55.","M85.2","H05.20","Z30.42","R56.9","D32.0","L73.2","M24.521","M25.361","G80.1","H53.143","H16.213","H52.13","E05.00","G93.89","M85.9","H05.242","E05.80","H25.13","N91.2","Z01.419","Z12.39","M21.061","M21.062","G93.1","M21.42","M21.41","R10.9","M89.9","Z20.828","F79.","D42.0","Z01.810","R94.31","Z86.73","G40.019","Z12.31","N92.6","Z11.1","Z92.3","Z86.011","I67.82"],"date":["2020-10-22","2020-10-22","2020-10-22","2021-01-12","2021-09-07","2021-03-30","2020-09-03","2021-09-10","2020-10-05","2021-02-25","2021-09-01","2021-04-05","2021-09-10","2021-04-05","2021-04-05","2021-04-05","2021-04-05","2021-08-26","2021-08-26","2020-09-17","2021-09-08","2021-09-29","2021-06-17","2021-09-08","2020-01-02","2021-07-12","2021-07-12","2021-10-28","2021-10-06","2021-10-06","2021-10-06","2020-07-20","2020-08-20","2020-08-20","2020-07-20","2020-07-08","2020-07-08","2020-07-09","2020-07-09","2020-07-09","2021-10-11","2021-10-11","2021-10-11","2020-10-12","2020-10-12","2020-08-20","2020-09-17","2020-11-10","2020-08-04","2021-09-01","2020-11-12","2020-11-12","2021-09-01","2021-08-26","2021-07-13","2021-07-14","2021-06-08","2021-09-08","2021-09-08","2021-09-01"],"priorHcc":["","","","",null,"","",null,"","",null,"",null,"","","","",null,null,"",null,null,"",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":[["","126001661","PREVIDENT","GEL 0.011","100","Select","Select",""],["","31722053705","LEVETIRACETA","TAB 500MG","60","Select","Select",""],["","69315090410","LORAZEPAM","TAB 0.5MG","5","Select","Select",""],["","24208083060","NEO\/POLY\/DEX","SUS 0.1% OP","-5","Select","Select",""],["","168005615","BETAMETH DIP","OIN 0.0005","-60","Select","Select",""],["","70461032003","FLUCLVX QUAD","INJ 2020-21","0","Select","Select",""],["","904645760","DOK","CAP 100MG","30","Select","Select",""],["","59762453701","MEDROXYPR AC","INJ 150MG\/ML","-1","Select","Select",""],["","998063006","MAXITROL","SUS 0.1% OP","5","Select","Select",""],["","69097014260","ALBUTEROL","AER HFA","27","Select","Select",""],["","60505082901","FLUTICASONE","SPR 50MCG","16","Select","Select",""],["","93506105","HYDROXYZ HCL","TAB 25MG","90","Select","Select",""],["","51672135203","DESOXIMETAS","OIN 0.0005","60","Select","Select",""],["","67618010160","COLACE","CAP 100MG","90","Select","Select",""],["","23155013525","DOXYCYC MONO","TAB 100MG","20","Select","Select",""],["","57237000630","FLUCONAZOLE","TAB 200MG","3","Select","Select",""],["","59762453701","MEDROXYPROGESTERONE ACETATE ","","-1","Select","Select",""],["","68180011302","LEVETIRACETAM ","","60","Select","Select",""],["","23155013525","DOXYCYCLINE MONOHYDRATE","","20","Select","Select",""],["","904645760","DOK ","","30","Select","Select",""],["","60505082901","FLUTICASONE PROPIONATE","","16","Select","Select",""],["","93506105","HYDROXYZINE HYDROCHLORIDE ","","90","Select","Select",""],["","24208079535","NEOMYCIN\/POLYMYXIN\/DEXAMETHASONE","","-4","Select","Select",""],["","69097014260","ALBUTEROL SULFATE HFA","","27","Select","Select",""],["","70461032003","FLUCELVAX QUADRIVALENT 2020-2021","","0","Select","Select",""],["","69315090410","LORAZEPAM ","","5","Select","Select",""],["","126001661","PREVIDENT 5000 DRY MOUTH","","100","Select","Select",""],["","168005615","BETAMETHASONE DIPROPIONATE","","60","Select","Select",""],["","51672135203","DESOXIMETASONE","","60","Select","Select",""],["","59762453701","MEDROXYPROGESTERONE ACETATE","","-1","Select","Select",""],["","68180011302","LEVETIRACETAM","","60","Select","Select",""],["","00093506105","HYDROXYZINE HYDROCHLORIDE","","90","Select","Select",""],["","65862085901","FAMOTIDINE","","90","Select","Select",""],["","41167412004","ALLEGRA ALLERGY","","90","Select","Select",""],["","19515081852","FLULAVAL QUADRIVALENT 2021-2022","2021-22","0","Select","Select",""],["","59762453701","MEDROXYPROGESTERONE ACETATE                                           ","INJ 150MG\/ML","-1","Select","Select",""],["","00093506105","HYDROXYZINE HYDROCHLORIDE                                             ","TAB 25MG","90","Select","Select",""],["","68180011302","LEVETIRACETAM                                                         ","TAB 500MG","60","Select","Select",""],["","60505082901","FLUTICASONE PROPIONATE                                                ","SPR 50MCG","16","Select","Select",""],["","00904645760","DOK                                                                   ","CAP 100MG","30","Select","Select",""],["","57237000630","FLUCONAZOLE                                                           ","TAB 200MG","3","Select","Select",""],["","24208079535","NEOMYCIN\/POLYMYXIN\/DEXAMETHASONE                                      ","OIN 0.1% OP","4","Select","Select",""],["","70461032003","FLUCELVAX QUADRIVALENT 2020-2021                                      ","INJ 2020-21","0","Select","Select",""],["","23155013525","DOXYCYCLINE MONOHYDRATE                                               ","TAB 100MG","20","Select","Select",""],["","67618010160","COLACE                                                                ","CAP 100MG","90","Select","Select",""],["","69097014260","ALBUTEROL SULFATE HFA                                                 ","AER HFA","27","Select","Select",""],["","00126001661","PREVIDENT 5000 DRY MOUTH                                              ","GEL 0.011","100","Select","Select",""],["","69315090410","LORAZEPAM                                                             ","TAB 0.5MG","5","Select","Select",""],["","00168005615","BETAMETHASONE DIPROPIONATE                                            ","OIN 0.0005","60","Select","Select",""],["","51672135203","DESOXIMETASONE                                                        ","OIN 0.0005","60","Select","Select",""],["","00998063006","MAXITROL                                                              ","SUS 0.1% OP","5","Select","Select",""],["","41167412004","ALLEGRA ALLERGY                                                       ","TAB 180MG","90","Select","Select",""],["","19515081852","FLULAVAL QUADRIVALENT 2021-2022                                       ","INJ 2021-22","0","Select","Select",""],["","65862085901","FAMOTIDINE                                                            ","TAB 20MG","90","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","",""],["No","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":""}]}]}