{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"TRACY   L JONES FITZGERALD","gend":1,"add":"171 EPPS ST","city":"DANVILLE","state":"VA","zip":"24541-9998","dob":"1984-02-07","age":"","mstatus":"","insh":"900047689*01","cliId":"4GM7PW4TW55","pno":"434\/709-6409","cno":"434\/709-6409","email":"","ename":"","eno":"","pphy":"ZHOU-TALBERT, SERENA MD","ppno":"336\/694-1181","pcpadd":"439 US HIGHWAY 158 WEST","pcpcity":"YANCEYVILLE","pcpstate":"NC","pcpzip":27379,"pcpcounty":"","pcpid":571290,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"336\/694-7511","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R53.1","R33.9","N39.0","R60.9","G35.","R26.89","I89.0","E66.9","Z46.6","N31.9","E66.01","F32.9","D50.9","E55.9","Z79.52","Z91.81","Z99.3","F33.40","Z68.41","M19.90","M10.9","Z87.891","Z98.51","Z91.013","J01.90","Z09.","R25.2","M25.60","Z86.19","E83.42","R82.90","M51.36","N13.30","R05.","T83.091A","R31.9","N17.9","E87.2","U07.1","A41.9","E87.6","D62.","K59.00","Z74.01","R53.81","R18.8","R10.84","T83.511D","R09.89","R59.9","R10.9","D70.9","T78.2XXA","Z71.89","M1A.9XX0","T83.511A","N13.6","B96.4","B37.9","N32.0","R53.83","R11.2"],"date":["2021-06-07","2021-09-07","2021-09-18","2021-08-10","2021-11-04","2021-06-02","2021-06-01","2021-09-13","2021-09-07","2021-09-07","2021-09-18","2021-09-07","2021-09-07","2021-09-07","2021-07-09","2021-09-07","2021-09-07","2021-06-02","2021-09-11","2021-06-02","2021-06-02","2021-06-02","2021-06-02","2021-06-02","2021-05-31","2021-07-27","2021-08-10","2021-08-10","2021-08-10","2021-09-11","2021-07-27","2021-08-10","2021-09-14","2021-09-16","2021-09-18","2021-09-18","2021-10-15","2021-09-18","2021-09-24","2021-09-18","2021-10-15","2021-09-18","2021-09-18","2021-09-24","2021-09-24","2021-09-11","2021-09-11","2021-09-28","2021-10-08","2021-09-11","2021-09-11","2021-09-18","2021-04-08","2021-05-20","2021-05-20","2021-09-11","2021-09-11","2021-09-11","2021-09-11","2021-09-11","2021-08-10","2021-09-10"],"priorHcc":["",null,null,null,null,"","",null,null,null,null,null,null,null,"",null,null,"",null,"","","","","","",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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":[["","00832105410","BACLOFEN","","540","Select","Select",""],["","13668013701","ESCITALOPRAM OXALATE","","90","Select","Select",""],["","00378021610","FUROSEMIDE","40MG","30","Select","Select",""],["","00245531911","KLOR-CON M20","20MEQ ER","30","Select","Select",""],["","55111012701","CIPROFLOXACIN HYDROCHLORIDE","500MG","14","Select","Select",""],["","69452015120","VITAMIN D","50000UNT","4","Select","Select",""],["","00527150237","AMPHETAMINE\/DEXTROAMPHETAMINE","10MG","60","Select","Select",""],["","00536100901","FERROUS SULFATE","325MG","45","Select","Select",""],["","55111012701","CIPROFLOXACIN HYDROCHLORIDE                                           ","TAB 500MG","14","Select","Select",""],["","00245531911","KLOR-CON M20                                                          ","TAB 20MEQ ER","30","Select","Select",""],["","13668013701","ESCITALOPRAM OXALATE                                                  ","TAB 20MG","90","Select","Select",""],["","00832105410","BACLOFEN                                                              ","TAB 10MG","540","Select","Select",""],["","69452015120","VITAMIN D                                                             ","CAP 50000UNT","4","Select","Select",""],["","00378021610","FUROSEMIDE                                                            ","TAB 40MG","30","Select","Select",""],["","00832532510","POTASSIUM CHLORIDE ER                                                 ","TAB 20MEQ ER","16","Select","Select",""],["","00536100901","FERROUS SULFATE                                                       ","TAB 325MG","45","Select","Select",""],["","53191036201","D3-50                                                                 ","CAP 50000UNT","1","Select","Select",""],["","00527150237","AMPHETAMINE\/DEXTROAMPHETAMINE                                         ","TAB 10MG","60","Select","Select",""],["","67877032101","IBUPROFEN                                                             ","TAB 800MG","26","Select","Select",""],["","75834002001","VITAMIN D3                                                            ","CAP 50000UNT","1","Select","Select",""],["","10006073038","MAGNESIUM OXIDE                                                       ","TAB 400MG","7","Select","Select",""],["","45802005911","NYSTATIN                                                              ","CRE 100000","30","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":""}]}]}