{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DOUGLAS   E HIGGINS","gend":0,"add":"1841 W MIDLAND TRL","city":"LEXINGTON","state":"VA","zip":"24450-9998","dob":"1964-08-13","age":"","mstatus":"","insh":"900039769*01","cliId":"3MD8KU0VD23","pno":"540\/460-4063","cno":"540\/460-4063","email":"","ename":"","eno":"","pphy":"","ppno":"","pcpadd":"","pcpcity":"","pcpstate":"","pcpzip":"","pcpcounty":"","pcpid":"","pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"ROANOKE ALLEGHANY","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":["M17.0","D51.9","F23.","E53.8","F20.9","F17.228","Z79.899","R73.09","L21.9","E03.9","K13.21","R60.0","H60.542","E66.9","S80.212A","Z23.","S80.211A","R60.9","R06.09","F17.220","R06.02","R73.01","R06.00","M79.89","Z12.11","R79.89","I51.7"],"date":["2020-10-07","2021-09-27","2021-09-22","2021-10-27","2021-06-15","2020-11-19","2021-06-16","2020-08-18","2020-08-18","2021-09-01","2020-08-18","2021-07-16","2020-08-18","2021-06-16","2021-06-26","2021-06-26","2021-06-26","2021-09-28","2021-09-28","2021-06-15","2021-08-04","2021-06-10","2021-06-10","2021-07-21","2021-05-23","2021-09-01","2021-08-04"],"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":[["","50458056401","INVEGA SUST","INJ 234\/1.5","2","Select","Select",""],["","168000615","TRIAMCINOLON","OIN 0.001","15","Select","Select",""],["","45802046564","KETOCONAZOLE","SHA 0.02","120","Select","Select",""],["","49281063315","FLUZONE QUAD","INJ 2020-21","0","Select","Select",""],["","50383090110","HC\/ACET ACID","SOL OTIC","10","Select","Select",""],["","168000615","TRIAMCINOLONE ACETONIDE","","15","Select","Select",""],["","50383090110","HYDROCORTISONE\/ACETIC ACID","","10","Select","Select",""],["","50458056401","INVEGA SUSTENNA ","","2","Select","Select",""],["","49281063315","FLUZONE QUADRIVALENT 2020-2021","","0","Select","Select",""],["","50458056401","INVEGA SUSTENNA","","2","Select","Select",""],["","00093101042","MUPIROCIN","","22","Select","Select",""],["","50458056401","INVEGA SUSTENNA                                                       ","INJ 234\/1.5","2","Select","Select",""],["","00168000615","TRIAMCINOLONE ACETONIDE                                               ","OIN 0.001","15","Select","Select",""],["","50383090110","HYDROCORTISONE\/ACETIC ACID                                            ","SOL OTIC","10","Select","Select",""],["","49281063315","FLUZONE QUADRIVALENT 2020-2021                                        ","INJ 2020-21","0","Select","Select",""],["","45802046564","KETOCONAZOLE                                                          ","SHA 0.02","120","Select","Select",""],["","65862002106","MIRTAZAPINE ODT                                                       ","TAB 15MG ODT","30","Select","Select",""],["","00093101042","MUPIROCIN                                                             ","OIN 0.02","22","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":""}]}]}