{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CHARLOTTE   A CLARK","gend":1,"add":"500 FARMER ST APT 218","city":"PETERSBURG","state":"VA","zip":"23803-9998","dob":"1962-03-27","age":"","mstatus":"","insh":"900047572*01","cliId":"6EU5T96YR97","pno":"804\/426-0544","cno":"804\/426-0544","email":"","ename":"","eno":"","pphy":"PARK, HYO K DO","ppno":"804\/469-3731","pcpadd":"13855 COURTHOUSE ROAD","pcpcity":"DINWIDDIE","pcpstate":"VA","pcpzip":23841,"pcpcounty":"","pcpid":112325,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"CENTRAL","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"804\/469-5307","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["I10.","E78.5","E66.9","J34.2","E04.1","Z12.31","R06.00","E04.2","Z76.89","R59.0","D64.9","D72.819","D73.89","K76.89","R68.89","R74.8","K57.30","R10.13","R59.9","R06.02","M79.602","R59.1","C85.90","R10.9","M25.532","M79.89","M79.622","G56.02","R91.8","M25.561","M17.11","G89.29","Z20.822","E07.9","E11.9","J45.40","Z20.828","K21.9"],"date":["2021-09-03","2021-04-09","2021-09-16","2021-04-09","2021-04-22","2021-04-12","2021-05-18","2021-05-18","2021-06-02","2021-09-16","2021-06-30","2021-06-30","2021-06-30","2021-06-30","2021-06-30","2021-06-30","2021-05-21","2021-05-21","2021-06-23","2021-08-26","2021-08-10","2021-08-11","2021-08-11","2021-08-11","2021-08-10","2021-08-10","2021-08-10","2021-08-10","2021-09-03","2021-09-17","2021-09-17","2021-09-17","2021-08-30","2021-09-03","2021-09-03","2021-09-16","2021-08-30","2021-09-03"],"priorHcc":[null,"",null,"","","","","","",null,"","","","","","","","","",null,"",null,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":[["","60505083305","AZELASTINE","SPR 0.001","-30","Select","Select",""],["","23155050105","HYDROXYZ HCL","TAB 25MG","30","Select","Select",""],["","378668999","PANTOPRAZOLE","TAB 40MG","30","Select","Select",""],["","43547028910","BUPROPION","TAB 150MG SR","180","Select","Select",""],["","68382079201","ACYCLOVIR","TAB 800MG","-6","Select","Select",""],["","29300012810","HYDROCHLOROT","TAB 25MG","-90","Select","Select",""],["","378668999","PANTOPRAZOLE SODIUM","","30","Select","Select",""],["","60505083305","AZELASTINE HYDROCHLORIDE","","-30","Select","Select",""],["","43547028910","BUPROPION HYDROCHLORIDE ER (SR) ","","180","Select","Select",""],["","29300012810","HYDROCHLOROTHIAZIDE","","90","Select","Select",""],["","23155050105","HYDROXYZINE HYDROCHLORIDE ","","30","Select","Select",""],["","68382079201","ACYCLOVIR ","","6","Select","Select",""],["","591079501","DICYCLOMINE HYDROCHLORIDE ","","20","Select","Select",""],["","68462010530","ONDANSETRON HYDROCHLORIDE ","","20","Select","Select",""],["","23155050105","HYDROXYZINE HYDROCHLORIDE","","30","Select","Select",""],["","43547028910","BUPROPION HYDROCHLORIDE ER (SR)","","180","Select","Select",""],["","68462010530","ONDANSETRON HYDROCHLORIDE","","20","Select","Select",""],["","31722088390","ROSUVASTATIN CALCIUM","","30","Select","Select",""],["","00591079501","DICYCLOMINE HYDROCHLORIDE","","20","Select","Select",""],["","00054032756","FLUTICASONE PROPIONATE\/SALMETEROL","250\/50","60","Select","Select",""],["","00591544305","PREDNISONE","20MG","-18","Select","Select",""],["","66993001968","ALBUTEROL SULFATE HFA","HFA","-18","Select","Select",""],["","00378932132","WIXELA INHUB","250\/50","60","Select","Select",""],["","65162010250","GABAPENTIN","300MG","90","Select","Select",""],["","16729013401","ALLOPURINOL","100MG","60","Select","Select",""],["","68382091634","METHYLPREDNISOLONE DOSE PACK","4MG","21","Select","Select",""],["","45802004475","ACYCLOVIR                                                             ","CRE 0.05","5","Select","Select",""],["","00378668999","PANTOPRAZOLE SODIUM                                                   ","TAB 40MG","90","Select","Select",""],["","60505083305","AZELASTINE HYDROCHLORIDE                                              ","SPR 0.001","30","Select","Select",""],["","29300012810","HYDROCHLOROTHIAZIDE                                                   ","TAB 25MG","90","Select","Select",""],["","43547028910","BUPROPION HYDROCHLORIDE ER (SR)                                       ","TAB 150MG SR","180","Select","Select",""],["","31722088390","ROSUVASTATIN CALCIUM                                                  ","TAB 10MG","90","Select","Select",""],["","23155050105","HYDROXYZINE HYDROCHLORIDE                                             ","TAB 25MG","30","Select","Select",""],["","68462010530","ONDANSETRON HYDROCHLORIDE                                             ","TAB 4MG","20","Select","Select",""],["","66993001968","ALBUTEROL SULFATE HFA                                                 ","AER HFA","-18","Select","Select",""],["","00591079501","DICYCLOMINE HYDROCHLORIDE                                             ","TAB 20MG","20","Select","Select",""],["","16729013401","ALLOPURINOL                                                           ","TAB 100MG","-60","Select","Select",""],["","60505082901","FLUTICASONE PROPIONATE                                                ","SPR 50MCG","-48","Select","Select",""],["","65162010250","GABAPENTIN                                                            ","CAP 300MG","-90","Select","Select",""],["","00591544305","PREDNISONE                                                            ","TAB 20MG","18","Select","Select",""],["","00054032756","FLUTICASONE PROPIONATE\/SALMETEROL                                     ","AER 250\/50","60","Select","Select",""],["","49502010202","EPINEPHRINE                                                           ","INJ 0.3MG","2","Select","Select",""],["","00378932132","WIXELA INHUB                                                          ","AER 250\/50","60","Select","Select",""],["","68382091634","METHYLPREDNISOLONE DOSE PACK                                          ","TAB 4MG","21","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":""}]}]}