{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"RUTH   C CARRIER","gend":1,"add":"476 WEST WOLFE ST","city":"HARRISONBURG","state":"VA","zip":"22802-9998","dob":"1938-06-15","age":"","mstatus":"","insh":"900041100*01","cliId":"2JC0W03KD12","pno":"540\/434-6053","cno":"540\/434-6053","email":"","ename":"","eno":"","pphy":"WITMAN, JOHN A MD","ppno":"540\/433-3344","pcpadd":"1751 ERICKSON AVENUE","pcpcity":"HARRISONBURG","pcpstate":"VA","pcpzip":22801,"pcpcounty":"","pcpid":972968,"pcpname":"Rockingham Family Physicians, PC","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"540\/433-0031","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M54.5","M81.0","I48.0","I10.","E78.5","K21.9","Z86.73","Z79.899","I48.91","Z23."],"date":["2021-01-04","2021-08-16","2021-02-17","2021-08-16","2021-08-16","2021-02-17","2021-02-17","2021-05-14","2021-08-16","2021-10-09"],"priorHcc":["",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":[["","000003089321","ELIQUIS ","2.5MG","60","Select","Select",""],["","000245003623","PREVALITE ","4GM","231","Select","Select",""],["","000378020810","FUROSEMIDE ","20MG","30","Select","Select",""],["","031722070290","LOSARTAN ","100MG","-45","Select","Select",""],["","055111015810","OMEPRAZOLE ","20MG","90","Select","Select",""],["","068180072103","AMLODIPINE ","10MG","90","Select","Select",""],["","051862024160","AMIODARONE ","200MG","90","Select","Select",""],["","069452015120","VITAMIN ","50000UNT","-12","Select","Select",""],["","076385011250","CARVEDILOL ","12.5MG","180","Select","Select",""],["","023155000810","HYDROCHLOROT ","25MG","-90","Select","Select",""],["","050742061610","METOPROL ","50MG ER","90","Select","Select",""],["","00003089321","","2.5MG","60","Select","Select",""],["","23155000810","HYDROCHLOROT","25MG","-90","Select","Select",""],["","00003089321","ELIQUIS","2.5MG","60","Select","Select",""],["","31722070290","LOSARTAN","100MG","-45","Select","Select",""],["","55111015810","OMEPRAZOLE","20MG","90","Select","Select",""],["","69452015120","VITAMIN","50000UNT","12","Select","Select",""],["","00245003623","PREVALITE","4GM","231","Select","Select",""],["","00378020810","FUROSEMIDE","20MG","90","Select","Select",""],["","51862024160","AMIODARONE","200MG","90","Select","Select",""],["","68180072103","AMLODIPINE","10MG","-90","Select","Select",""],["","50742061610","METOPROL","50MG ER","90","Select","Select",""],["","76385011250","CARVEDILOL","12.5MG","180","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":""}]}]}