{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ARLENE DAVIS","gend":1,"add":"1202 CUSTER ST","city":"PETERSBURG","state":"VA","zip":"23803-9998","dob":"1963-08-09","age":"","mstatus":"","insh":"900037619*01","cliId":"7X54YT2RA93","pno":"804\/835-9359","cno":"804\/835-9359","email":"","ename":"","eno":"","pphy":"SARAIYA, BHAVNA MD","ppno":"","pcpadd":"50 MEDICAL PARK BLVD SUITE C","pcpcity":"PETERSBURG","pcpstate":"VA","pcpzip":23805,"pcpcounty":"","pcpid":208807,"pcpname":"SOUTHSIDE PHYSICIANS NETWORK - INTERNAL MEDICINE","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"CENTRAL","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":["M25.562","M17.12","M54.5","R03.0","K59.00","L30.4","E78.00","E66.01","G89.29","Z68.42","M25.662","M62.81","M79.89","R26.89","R68.89","Z74.09","E78.5","Z20.828","G47.8","R27.9","R60.0","Z73.6","H40.023","N39.0","R14.0","B35.1","M72.2","M76.62","H40.1131","H25.13","H04.123","L60.8","R05.","H43.811","Z51.89","R10.9","K57.30","M75.51","M25.511","R29.3","M25.611","Z72.89","R26.81","R53.1","Z01.419","Z12.31","Z90.710","Z11.3","B35.3","M54.9","M19.011","M75.81","K21.9","R10.31","M79.605","M25.462","Z51.81","R31.9","R31.0","M48.061","M17.11","M47.816","M17.0","U07.1","J12.82","J96.01","Z68.41","E87.6","T38.0X5A","B02.9","Z79.84","R06.02","M25.50","M79.10","M54.6","J06.9","H40.9","J44.9","M19.90","Z79.899","Z68.39","R07.2","R06.00","Z86.16","Z04.9","E11.65","Z09.","Z87.898","M15.9","R07.9","M25.519","R79.1","R91.8","M47.814","M54.16","M79.603","R00.1","J98.11","I51.7","G47.30","J45.30","G47.10","R06.83","Z72.821","G47.00","M51.36","R09.02","M46.96","M53.86","R26.9","G47.33","M54.50","R53.81"],"date":["2021-06-10","2021-05-07","2021-09-24","2020-09-17","2021-01-18","2020-09-17","2021-05-18","2021-10-06","2021-06-10","2021-04-08","2021-01-07","2021-01-07","2020-10-01","2021-10-06","2020-11-13","2021-10-06","2021-06-04","2020-12-04","2021-01-07","2021-01-07","2021-01-07","2021-01-07","2021-09-14","2021-03-23","2021-03-23","2020-05-07","2020-05-28","2020-06-26","2021-01-06","2021-09-14","2021-09-14","2020-01-15","2021-09-22","2020-03-10","2020-06-26","2020-09-11","2020-09-11","2020-11-13","2020-11-13","2020-11-13","2020-11-13","2020-12-10","2020-12-10","2021-10-06","2021-03-16","2021-03-31","2021-03-16","2021-03-16","2020-02-12","2021-05-12","2020-10-16","2020-10-16","2021-01-13","2020-09-11","2020-07-15","2020-07-15","2021-05-07","2021-03-23","2021-03-23","2021-09-30","2021-05-07","2021-09-30","2021-05-07","2021-06-11","2021-09-22","2021-05-28","2021-06-10","2021-05-24","2021-05-21","2021-06-10","2021-06-04","2021-09-22","2021-05-16","2021-05-16","2021-05-16","2021-05-16","2021-05-18","2021-05-18","2021-05-16","2021-05-18","2021-05-07","2021-05-18","2021-06-04","2021-10-06","2021-06-04","2021-06-10","2021-06-10","2021-06-10","2021-06-10","2021-06-04","2021-05-18","2021-06-04","2021-06-11","2021-06-11","2021-07-06","2021-05-18","2021-05-25","2021-05-18","2021-05-18","2021-06-29","2021-09-22","2021-09-22","2021-09-22","2021-09-22","2021-09-22","2021-10-06","2021-05-21","2021-09-30","2021-10-06","2021-09-24","2021-09-22","2021-10-06","2021-10-06"],"priorHcc":["","",null,"","","","",null,"","","","","",null,"",null,"","","","","","",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":[["","23320503","LUMIGAN","SOL 0.0001","2","Select","Select",""],["","49483060450","IBUPROFEN","TAB 800MG","60","Select","Select",""],["","69097052444","DICLOFENAC","GEL 0.01","200","Select","Select",""],["","10702002501","PHENTERMINE","TAB 37.5MG","30","Select","Select",""],["","93720298","PRAVASTATIN","TAB 40MG","90","Select","Select",""],["","456120230","LINZESS","CAP 290MCG","30","Select","Select",""],["","69097015907","MELOXICAM","TAB 15MG","30","Select","Select",""],["","70377002811","ATORVASTATIN","TAB 20MG","90","Select","Select",""],["","69097085902","TERBINAFINE","TAB 250MG","30","Select","Select",""],["","50383023310","DORZOL\/TIMOL","SOL 22.3-6.8","10","Select","Select",""],["","65862039010","ONDANSETRON","TAB 4MG ODT","12","Select","Select",""],["","51672404801","CLOTRIM\/BETA","CRE DIPROP","45","Select","Select",""],["","23916360","RESTASIS","EMU 0.0005","60","Select","Select",""],["","536128128","LIDOCAINE","CRE 0.04","30","Select","Select",""],["","65162019050","NAPROXEN","TAB 500MG","20","Select","Select",""],["","69543042610","NAPROXEN DR","TAB 500MG","28","Select","Select",""],["","378064205","PREDNISONE","TAB 20MG","7","Select","Select",""],["","68180012202","CEPHALEXIN","CAP 500MG","21","Select","Select",""],["","62541020130","QSYMIA","CAP 3.75-23","14","Select","Select",""],["","53746010901","HYDROCO\/APAP","TAB 5-325MG","15","Select","Select",""],["","378967130","IPRATROPIUM\/","SOL ALBUTER","360","Select","Select",""],["","378932132","WIXELA INHUB","AER 250\/50","180","Select","Select",""],["","70710113908","FLUCONAZOLE","TAB 150MG","1","Select","Select",""],["","23320503","LUMIGAN ","","2","Select","Select",""],["","61314003002","DORZOLAMIDE HCL\/TIMOLOL MALEATE ","","10","Select","Select",""],["","69097085902","TERBINAFINE HCL ","","90","Select","Select",""],["","456120230","LINZESS ","","30","Select","Select",""],["","69097015907","MELOXICAM ","","30","Select","Select",""],["","51672404801","CLOTRIMAZOLE\/BETAMETHASONE DIPROPIONATE ","","45","Select","Select",""],["","70377002811","ATORVASTATIN CALCIUM ","","90","Select","Select",""],["","536128128","LIDOCAINE ","","30","Select","Select",""],["","16571020106","DICLOFENAC SODIUM DR ","","60","Select","Select",""],["","53746010901","HYDROCODONE\/ACETAMINOPHEN ","","15","Select","Select",""],["","378967130","IPRATROPIUM BROMIDE\/ALBUTEROL SULFATE ","","360","Select","Select",""],["","65862039010","ONDANSETRON ODT ","","12","Select","Select",""],["","10702002501","PHENTERMINE HCL ","","30","Select","Select",""],["","69097052444","DICLOFENAC SODIUM","","-200","Select","Select",""],["","93720298","PRAVASTATIN SODIUM ","","90","Select","Select",""],["","49483060450","IBUPROFEN ","","60","Select","Select",""],["","69842087651","CVS ACETAMINOPHEN","","20","Select","Select",""],["","93005805","TRAMADOL HCL","","30","Select","Select",""],["","68382075810","METFORMIN HYDROCHLORIDE","","60","Select","Select",""],["","53885039310","ONETOUCH ULTRASOFT LANCETS","","100","Select","Select",""],["","378827052","ALBUTEROL SULFATE","","75","Select","Select",""],["","59310058020","PROAIR RESPICLICK","","1","Select","Select",""],["","69097094312","GABAPENTIN","","60","Select","Select",""],["","54418625","DEXAMETHASONE ","","5","Select","Select",""],["","69842080601","CVS MUCUS EXTENDED RELEASE","","20","Select","Select",""],["","53885024510","ONETOUCH ULTRA","","100","Select","Select",""],["","53885044801","ONETOUCH ULTRA 2","","1","Select","Select",""],["","42858010201","OXYCODONE\/ACETAMINOPHEN","","12","Select","Select",""],["","31722070530","VALACYCLOVIR HCL","","20","Select","Select",""],["","50428085942","CVS PREP PADS ","","100","Select","Select",""],["","69097085902","TERBINAFINE HCL","","90","Select","Select",""],["","61314003002","DORZOLAMIDE HCL\/TIMOLOL MALEATE","","10","Select","Select",""],["","51672404801","CLOTRIMAZOLE\/BETAMETHASONE DIPROPIONATE","","45","Select","Select",""],["","70377002811","ATORVASTATIN CALCIUM","","90","Select","Select",""],["","16571020106","DICLOFENAC SODIUM DR","","60","Select","Select",""],["","53746010901","HYDROCODONE\/ACETAMINOPHEN","","15","Select","Select",""],["","65862039010","ONDANSETRON ODT","","12","Select","Select",""],["","00378967130","IPRATROPIUM BROMIDE\/ALBUTEROL SULFATE","","-360","Select","Select",""],["","00093720298","PRAVASTATIN SODIUM","","90","Select","Select",""],["","10702002501","PHENTERMINE HCL","","30","Select","Select",""],["","00054418625","DEXAMETHASONE","","5","Select","Select",""],["","50428085942","CVS PREP PADS","","100","Select","Select",""],["","00186037020","SYMBICORT","","10","Select","Select",""],["","00310737020","BUDESONIDE\/FORMOTEROL FUMARATE DIHYDRATE","","10","Select","Select",""],["","59651000305","OMEPRAZOLE DR","","30","Select","Select",""],["","59779076678","CVS PAIN RELIEF REGULAR STRENGTH","","20","Select","Select",""],["","71930005552","ACETAMINOPHEN\/CODEINE PHOSPHATE","300-30MG","30","Select","Select",""],["","51672404801","CLOTRIMAZOLE\/BETAMETHASONE DIPROPIONATE                               ","CRE DIPROP","45","Select","Select",""],["","69097085902","TERBINAFINE HCL                                                       ","TAB 250MG","30","Select","Select",""],["","00456120230","LINZESS                                                               ","CAP 290MCG","30","Select","Select",""],["","69097015807","MELOXICAM                                                             ","TAB 7.5MG","30","Select","Select",""],["","70377002811","ATORVASTATIN CALCIUM                                                  ","TAB 20MG","90","Select","Select",""],["","00536128128","LIDOCAINE                                                             ","CRE 0.04","30","Select","Select",""],["","50383023310","DORZOLAMIDE HCL\/TIMOLOL MALEATE                                       ","SOL 22.3-6.8","10","Select","Select",""],["","00023320503","LUMIGAN                                                               ","SOL 0.0001","8","Select","Select",""],["","16571020106","DICLOFENAC SODIUM DR                                                  ","TAB 75MG DR","60","Select","Select",""],["","53746010901","HYDROCODONE\/ACETAMINOPHEN                                             ","TAB 5-325MG","15","Select","Select",""],["","65162019050","NAPROXEN                                                              ","TAB 500MG","60","Select","Select",""],["","00378932132","WIXELA INHUB                                                          ","AER 250\/50","180","Select","Select",""],["","69543042610","NAPROXEN DR                                                           ","TAB 500MG","28","Select","Select",""],["","00378967130","IPRATROPIUM BROMIDE\/ALBUTEROL SULFATE                                 ","SOL ALBUTER","-360","Select","Select",""],["","10702002501","PHENTERMINE HCL                                                       ","TAB 37.5MG","30","Select","Select",""],["","69097052444","DICLOFENAC SODIUM                                                     ","GEL 0.01","200","Select","Select",""],["","00378064205","PREDNISONE                                                            ","TAB 20MG","7","Select","Select",""],["","00023916360","RESTASIS                                                              ","EMU 0.0005","60","Select","Select",""],["","65862039010","ONDANSETRON ODT                                                       ","TAB 4MG ODT","12","Select","Select",""],["","70710113908","FLUCONAZOLE                                                           ","TAB 150MG","1","Select","Select",""],["","00093720298","PRAVASTATIN SODIUM                                                    ","TAB 40MG","90","Select","Select",""],["","49483060450","IBUPROFEN                                                             ","TAB 800MG","60","Select","Select",""],["","68180012202","CEPHALEXIN                                                            ","CAP 500MG","21","Select","Select",""],["","00186037020","SYMBICORT                                                             ","AER 160-4.5","10","Select","Select",""],["","59651000305","OMEPRAZOLE DR                                                         ","CAP 40MG","90","Select","Select",""],["","62541020130","QSYMIA                                                                ","CAP 3.75-23","14","Select","Select",""],["","69097094312","GABAPENTIN                                                            ","CAP 300MG","60","Select","Select",""],["","53885024510","ONETOUCH ULTRA                                                        ","TES ULTRA","100","Select","Select",""],["","69842087651","CVS ACETAMINOPHEN                                                     ","TAB 325MG","20","Select","Select",""],["","68382075810","METFORMIN HYDROCHLORIDE                                               ","TAB 500MG","60","Select","Select",""],["","69842080601","CVS MUCUS EXTENDED RELEASE                                            ","TAB 600MG","20","Select","Select",""],["","00054418625","DEXAMETHASONE                                                         ","TAB 6MG","5","Select","Select",""],["","00378827052","ALBUTEROL SULFATE                                                     ","NEB 0.00083","75","Select","Select",""],["","31722070530","VALACYCLOVIR HCL                                                      ","TAB 1GM","20","Select","Select",""],["","42858010201","OXYCODONE\/ACETAMINOPHEN                                               ","TAB 5-325MG","12","Select","Select",""],["","00093005805","TRAMADOL HCL                                                          ","TAB 50MG","30","Select","Select",""],["","00310737020","BUDESONIDE\/FORMOTEROL FUMARATE DIHYDRATE                              ","AER 160-4.5","10","Select","Select",""],["","59779076678","CVS PAIN RELIEF REGULAR STRENGTH                                      ","TAB 325MG","20","Select","Select",""],["","71930005552","ACETAMINOPHEN\/CODEINE PHOSPHATE                                       ","TAB 300-30MG","30","Select","Select",""],["","59310058020","PROAIR RESPICLICK                                                     ","AER ","1","Select","Select",""],["","53885039310","ONETOUCH ULTRASOFT LANCETS                                            ","MIS LANCETS","100","Select","Select",""],["","50428085942","CVS PREP PADS                                                         ","PAD ","100","Select","Select",""],["","53885044801","ONETOUCH ULTRA 2                                                      ","KIT ULTRA 2","1","Select","Select",""],["","42632003232","CVS ADVANCED BLOOD PRESSURE MONITOR                                   ","MIS ADVANCED","1","Select","Select",""],["","16729018201","HYDROCHLOROTHIAZIDE                                                   ","TAB 12.5MG","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":[[["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":""}]}]}