{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"GLORIA   C DONOVAN","gend":1,"add":"3960 GUARD HILL RD","city":"FRONT ROYAL","state":"VA","zip":"22630-9998","dob":"1952-10-04","age":"","mstatus":"","insh":"900042499*01","cliId":"3XR1K60EP03","pno":"540\/551-3825","cno":"540\/551-3825","email":"","ename":"","eno":"","pphy":"","ppno":"","pcpadd":"","pcpcity":"","pcpstate":"","pcpzip":"","pcpcounty":"","pcpid":"","pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"NORTHERN & WINCHESTER","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":["Z51.81","Z79.01","I48.91","E11.9","I48.20","E78.00","E55.9","E53.8","Z12.2","M51.35","Z87.891","L53.9","J44.9","I10.","D64.9","Z12.31","R07.9","E78.5"],"date":["2021-09-07","2021-09-07","2021-09-10","2021-10-01","2021-10-01","2021-10-01","2021-10-01","2021-10-01","2021-05-10","2021-05-10","2021-05-10","2021-07-14","2021-07-14","2021-09-17","2021-10-01","2021-09-27","2021-09-16","2021-09-10"],"priorHcc":[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":[["","93505998","ATORVASTATIN","TAB 20MG","90","Select","Select",""],["","50111056001","TRAZODONE","TAB 50MG","90","Select","Select",""],["","57237012301","WARFARIN","TAB 4MG","90","Select","Select",""],["","56151146004","TRUE METRIX","TES GLUCOSE","50","Select","Select",""],["","68645055654","LISINOP\/HCTZ","TAB 10-12.5","90","Select","Select",""],["","68645052254","SERTRALINE","TAB 50MG","90","Select","Select",""],["","68645057290","GLIMEPIRIDE","TAB 2MG","-90","Select","Select",""],["","57237010099","METOPROL TAR","TAB 25MG","180","Select","Select",""],["","67877041301","METFORMIN","TAB 500MG ER","180","Select","Select",""],["","65162063609","PANTOPRAZOLE","TAB 20MG","180","Select","Select",""],["","56151146004","TRUE METRIX BLOOD GLUCOSETEST STRIPS","","50","Select","Select",""],["","50111056001","TRAZODONE HYDROCHLORIDE","","90","Select","Select",""],["","68645055654","LISINOPRIL\/HYDROCHLOROTHIAZIDE","","90","Select","Select",""],["","67877041301","METFORMIN HYDROCHLORIDE ER","","180","Select","Select",""],["","93505998","ATORVASTATIN CALCIUM ","","90","Select","Select",""],["","68645052254","SERTRALINE HCL","","90","Select","Select",""],["","57237012301","WARFARIN SODIUM ","","90","Select","Select",""],["","57237010099","METOPROLOL TARTRATE","","180","Select","Select",""],["","65162063609","PANTOPRAZOLE SODIUM","","180","Select","Select",""],["","78742026480","","","100","Select","Select",""],["","57237012301","WARFARIN SODIUM","","90","Select","Select",""],["","00093505998","ATORVASTATIN CALCIUM","","90","Select","Select",""],["","45802006436","TRIAMCINOLONE ACETONIDE","0.10%","80","Select","Select",""],["","56151146304","TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS","GLUCOSE","50","Select","Select",""],["","56151146004","TRUE METRIX BLOOD GLUCOSETEST STRIPS                                  ","TES GLUCOSE","100","Select","Select",""],["","57237010099","METOPROLOL TARTRATE                                                   ","TAB 25MG","180","Select","Select",""],["","68645057290","GLIMEPIRIDE                                                           ","TAB 2MG","90","Select","Select",""],["","50111056001","TRAZODONE HYDROCHLORIDE                                               ","TAB 50MG","90","Select","Select",""],["","57237012301","WARFARIN SODIUM                                                       ","TAB 4MG","90","Select","Select",""],["","00093505998","ATORVASTATIN CALCIUM                                                  ","TAB 20MG","90","Select","Select",""],["","65162063609","PANTOPRAZOLE SODIUM                                                   ","TAB 20MG","180","Select","Select",""],["","67877041301","METFORMIN HYDROCHLORIDE ER                                            ","TAB 500MG ER","180","Select","Select",""],["","45802006436","TRIAMCINOLONE ACETONIDE                                               ","CRE 0.001","80","Select","Select",""],["","78742026480","                                                                      "," ","100","Select","Select",""],["","68645052254","SERTRALINE HCL                                                        ","TAB 50MG","-90","Select","Select",""],["","68645055654","LISINOPRIL\/HYDROCHLOROTHIAZIDE                                        ","TAB 10-12.5","90","Select","Select",""],["","21292000619","TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS                      ","TES GLUCOSE","50","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":""}]}]}