{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DONNA   A AMOS","gend":1,"add":"1100 ASH HILL CT","city":"CHESAPEAKE","state":"VA","zip":"23322-9998","dob":"1972-01-19","age":"","mstatus":"","insh":"900047449*01","cliId":"2N71DK0YC17","pno":"757\/778-0592","cno":"757\/778-0592","email":"","ename":"","eno":"","pphy":"LAIBSTAIN, ROBERT B MD","ppno":"757\/420-8297","pcpadd":"1016 JUSTIS ST","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":23325,"pcpcounty":"","pcpid":163774,"pcpname":"INDIAN RIVER FAMILY PRACTICE","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"757\/737-0007","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":["K80.20","K83.8","D35.02","K80.00","K80.12","R10.11","M19.90","N28.1","K76.0","J44.9","K21.9","M79.7","M32.9","R79.89","J98.11","M51.36","G47.30","F17.210","Z79.899","R10.9","M54.5","Z90.710","Z90.49","R11.2","R19.7","M79.605","M54.42","R10.30","R20.0","R20.2","Z79.891","Z98.890","K57.10","K80.51","K83.1","E43.","F10.10","M06.9","F10.99","R94.5"],"date":["2021-07-09","2021-07-16","2021-07-22","2021-07-16","2021-07-16","2021-07-16","2021-07-16","2021-07-16","2021-07-22","2021-07-16","2021-07-16","2021-07-16","2021-07-16","2021-07-16","2021-07-16","2021-07-16","2021-07-16","2021-07-21","2021-07-21","2021-07-22","2021-07-22","2021-07-22","2021-07-22","2021-07-09","2021-07-09","2021-07-30","2021-07-21","2021-07-21","2021-07-21","2021-07-21","2021-07-21","2021-07-21","2021-07-08","2021-07-08","2021-07-06","2021-07-06","2021-07-06","2021-07-06","2021-07-08","2021-07-08"],"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":[["","65862090901","CELECOXIB","CAP 200MG","30","Select","Select",""],["","68382009601","HYDROXYCHLOR","TAB 200MG","-60","Select","Select",""],["","68382050010","OMEPRAZOLE","CAP 40MG","90","Select","Select",""],["","65862090901","CELECOXIB ","","-30","Select","Select",""],["","68382009601","HYDROXYCHLOROQUINE SULFATE","","60","Select","Select",""],["","65862085901","FAMOTIDINE","20MG","60","Select","Select",""],["","00591352530","LIDOCAINE","5%","30","Select","Select",""],["","00132020140","FLEET ENEMA","","133","Select","Select",""],["","70010077001","METHOCARBAMOL","750MG","20","Select","Select",""],["","00406051205","OXYCODONE\/ACETAMINOPHEN","5-325MG","20","Select","Select",""],["","51079030630","POLYETHYLENE GLYCOL 3350","3350 NF","30","Select","Select",""],["","68382050010","OMEPRAZOLE                                                            ","CAP 40MG","90","Select","Select",""],["","65862090901","CELECOXIB                                                             ","CAP 200MG","-30","Select","Select",""],["","68382009601","HYDROXYCHLOROQUINE SULFATE                                            ","TAB 200MG","-60","Select","Select",""],["","00591352530","LIDOCAINE                                                             ","PAD 0.05","30","Select","Select",""],["","00406051205","OXYCODONE\/ACETAMINOPHEN                                               ","TAB 5-325MG","20","Select","Select",""],["","70010077001","METHOCARBAMOL                                                         ","TAB 750MG","-20","Select","Select",""],["","00172572860","FAMOTIDINE                                                            ","TAB 20MG","-60","Select","Select",""],["","51079030630","POLYETHYLENE GLYCOL 3350                                              ","POW 3350 NF","30","Select","Select",""],["","70954005920","PREDNISONE                                                            ","TAB 10MG","45","Select","Select",""],["","00132020140","FLEET ENEMA                                                           ","ENE ","133","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":""}]}]}