{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" DOROTHY P MARTIN","gend":1,"add":"933 CHERRY STEET EXT","city":"MARTINSVILLE","state":"VA","zip":"24112-9998","dob":"1930-09-29","age":"","mstatus":"","insh":"900046541*01","cliId":"","pno":"276\/632-9114","cno":"276\/632-9114, ","email":"","ename":"","eno":"","pphy":"ZIMMER, WILLIAM J MD","ppno":"276\/670-3300","pcpadd":"STE A 1107 BROOKDALE ST","pcpcity":"MARTINSVILLE","pcpstate":"VA","pcpzip":24112,"pcpcounty":"","pcpid":147720,"pcpname":"Carilion Medical Associates Martinsville","plan":"OHP - OPTIMA","program":"MEDICARE","lob":"DSNP","region":"ROANOKE\/ ALLEGHANY","aligned":"Y","ano":"276\/632-9114, ","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":["Z45.2","Z86.16","L97.429","M86.9","N18.31","U07.1","E11.22","I50.32","D63.1","I10.","E78.5","M19.90","F03.90","K21.9","F32.9","R26.81","M62.81","R13.12","R26.2","R13.19","B37.49","L89.629"],"date":["2021-03-19","2021-03-19","2021-03-15","2021-03-15","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-03-01","2021-05-09"],"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":[["","68180051303","LISINOPRIL","TAB 5MG","30","Select","Select",""],["","70594004203","VANCOMYCIN","INJ 1GM\/200M","800","Select","Select",""],["","68180047802","SIMVASTATIN","TAB 10MG","30","Select","Select",""],["","93221001","SUCRALFATE","TAB 1GM","60","Select","Select",""],["","60505014101","GLIPIZIDE","TAB 5MG","8","Select","Select",""],["","65862014205","CARVEDILOL","TAB 3.125MG","36","Select","Select",""],["","65862049001","QUETIAPINE","TAB 50MG","90","Select","Select",""],["","378020810","FUROSEMIDE","TAB 20MG","45","Select","Select",""],["","33342002815","DONEPEZIL","TAB 10MG","4","Select","Select",""],["","62175061743","PANTOPRAZOLE","TAB 40MG","30","Select","Select",""],["","8290306546","NORMAL SALIN","INJ 0.009","600","Select","Select",""],["","68180012202","CEPHALEXIN","CAP 500MG","12","Select","Select",""],["","67877056860","DRONABINOL","CAP 2.5MG","14","Select","Select",""],["","57664051083","MIRTAZAPINE","TAB 7.5MG","30","Select","Select",""],["","50484001030","SANTYL","OIN 250\/GM","30","Select","Select",""],["","65862049001","QUETIAPINE FUMARATE","","90","Select","Select",""],["","60505014101","GLIPIZIDE ","","90","Select","Select",""],["","62175061743","PANTOPRAZOLE SODIUM","","90","Select","Select",""],["","8290306546","NORMAL SALINE FLUSH","","600","Select","Select",""],["","70594004203","VANCOMYCIN HYDROCHLORIDE","","800","Select","Select",""],["","33342002815","DONEPEZIL HCL ","","4","Select","Select",""],["","51672411606","METRONIDAZOLE ","","45","Select","Select",""],["","0","","","120","Select","Select",""],["","33342002815","DONEPEZIL HCL","","30","Select","Select",""],["","51672421503","METRONIDAZOLE","","60","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","",""],["No","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":""}]}]}