{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CHARLES   H WELLS","gend":0,"add":"57 WHITETAIL RUN LN","city":"WAYNESBORO","state":"VA","zip":"22980-9998","dob":"1962-12-07","age":"","mstatus":"","insh":"900046468*01","cliId":"4V05K27UF92","pno":"540\/448-3366","cno":"540\/448-3366","email":"","ename":"","eno":"","pphy":"LEE, DONALD W MD","ppno":"540\/949-8241","pcpadd":"428 S MAGNOLIA AVE","pcpcity":"WAYNESBORO","pcpstate":"VA","pcpzip":22980,"pcpcounty":"","pcpid":118165,"pcpname":"Carilion Family Medicine Associated Physicians","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"540\/949-5582","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["A41.50","A41.02","N13.6","E87.1","E87.2","N17.9","Q61.02","R65.20","I12.9","N18.9","E87.6","F32.9","D47.3","K21.9","F17.210","J44.9","E66.9","F41.8","R10.84","R10.30","R11.2","R19.7","R00.0","A41.01","M54.9","G89.29","N28.1","N20.1","N20.2","N20.0","N12.","Z03.818","Z86.14","I10.","E78.00","Z79.82","Z72.0","Z79.899"],"date":["2021-04-25","2021-04-25","2021-04-25","2021-04-25","2021-04-25","2021-04-25","2021-04-25","2021-04-25","2021-04-25","2021-04-25","2021-04-25","2021-05-24","2021-04-25","2021-05-24","2021-04-23","2021-04-23","2021-04-23","2021-04-23","2021-04-23","2021-04-23","2021-04-23","2021-04-23","2021-04-25","2021-04-25","2021-04-25","2021-04-25","2021-06-30","2021-06-30","2021-06-30","2021-05-24","2021-04-26","2021-04-23","2021-05-24","2021-05-24","2021-05-24","2021-05-24","2021-05-24","2021-05-24"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",""]}},{"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":[["","65862042005","SMZ\/TMP DS","TAB 800-160","28","Select","Select",""],["","51991074890","DULOXETINE","CAP 60MG","180","Select","Select",""],["","68382097001","CHLORTHALID","TAB 25MG","-135","Select","Select",""],["","59779043951","CVS ASPIRIN","TAB 81MG EC","90","Select","Select",""],["","68180098103","LISINOPRIL","TAB 20MG","90","Select","Select",""],["","68382097001","CHLORTHALIDONE","","-45","Select","Select",""],["","65862042005","SULFAMETHOXAZOLE\/TRIMETHOPRIM DS","","-28","Select","Select",""],["","51991074890","DULOXETINE HYDROCHLORIDE","","180","Select","Select",""],["","59779043951","CVS ASPIRIN LOW STRENGTH","","90","Select","Select",""],["","65862039010","ONDANSETRON ODT ","","10","Select","Select",""],["","65862039010","ONDANSETRON ODT","","10","Select","Select",""],["","65862042005","SULFAMETHOXAZOLE\/TRIMETHOPRIM DS                                      ","TAB 800-160","28","Select","Select",""],["","68180098103","LISINOPRIL                                                            ","TAB 20MG","90","Select","Select",""],["","68382097001","CHLORTHALIDONE                                                        ","TAB 25MG","135","Select","Select",""],["","51991074890","DULOXETINE HYDROCHLORIDE                                              ","CAP 60MG","180","Select","Select",""],["","59779043951","CVS ASPIRIN LOW STRENGTH                                              ","TAB 81MG EC","90","Select","Select",""],["","65862039010","ONDANSETRON ODT                                                       ","TAB 4MG ODT","10","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","",""],["Yes","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":""}]}]}