{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARITZA ORTIZ","gend":1,"add":"18 GRADY CRES","city":"CHESAPEAKE","state":"VA","zip":"23324-9998","dob":"1987-06-16","age":"","mstatus":"","insh":"1238252*01","cliId":"","pno":"757\/381-1269","cno":"757\/381-1269","email":"","ename":"","eno":"","pphy":"MEBRAHTU, SEMRET T MD","ppno":"757\/395-6900","pcpadd":"184B LASKIN RD","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23451,"pcpcounty":"","pcpid":117346,"pcpname":"SMG - Sentara Primary Care & Therapy Center - Oceanfront","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"","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":["K29.00","K22.6","Z98.84","J45.909","F32.9","F41.9","K20.9","S62.201A","S01.81XA","S09.90XA","S05.11XA","E34.8","K91.2","K21.9","K59.00","E66.9","Z90.3","K29.01","S62.627A","M20.012","R63.4","L65.9","Z68.30","Z20.828","R50.9","J02.9","S62.665K","M79.645","V54.12","S93.602A","K25.9","K22.10","Z68.35","R11.0","R10.84","S62.637A","S60.512A","E11.9","Z87.891","Z79.899","S69.92XA","C48.2","R10.2","V58.89","K29.70","J45.20","Z68.31","S63.641A","S62.637B","S62.637K","Z68.36","R23.2","C56.9","Z11.4","Z11.59","E66.01","K21.0","K25.4","M19.90","Z85.43","Z98.891","Z90.49","Z90.710","Z80.8","Z83.3","K92.0","R10.13","R00.1","E66.3","E78.2","R58.","Z74.2","M51.36","M54.16","M46.1","B37.2","Z01.810","Z01.811","Z01.812","R94.31","Z20.822","E87.2","E87.6","E83.42","K52.9"],"date":["2020-01-29","2021-05-11","2021-05-11","2020-09-02","2020-10-21","2020-09-02","2020-01-28","2020-01-31","2020-09-30","2020-09-30","2020-09-30","2020-09-30","2021-04-09","2021-05-11","2021-01-07","2021-05-11","2021-04-09","2020-01-27","2020-12-08","2020-12-08","2020-03-16","2020-03-16","2020-03-16","2020-11-08","2020-11-08","2020-11-08","2020-12-08","2020-12-17","2021-02-03","2020-03-31","2020-10-13","2020-10-13","2021-04-09","2020-01-27","2020-01-27","2020-10-20","2020-09-02","2020-09-02","2020-09-02","2020-09-02","2020-09-02","2020-10-05","2020-10-05","2020-10-21","2020-10-21","2020-10-21","2020-10-21","2020-03-05","2020-09-01","2020-12-08","2021-05-11","2020-09-23","2020-09-23","2020-10-01","2020-10-01","2021-09-16","2020-01-27","2020-01-27","2020-01-27","2020-01-28","2020-01-27","2020-01-28","2020-01-27","2020-01-27","2020-01-27","2020-01-28","2020-01-28","2020-01-27","2020-08-28","2020-08-28","2020-09-30","2020-09-30","2021-06-14","2021-06-14","2021-06-14","2021-08-04","2021-09-16","2021-09-16","2021-09-16","2021-09-16","2021-10-19","2021-10-19","2021-10-19","2021-10-19","2021-10-19"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",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":[["","62175061743","PANTOPRAZOLE ","40MG","60","Select","Select",""],["","57664012688","HYDROCO\/APAP ","5-325MG","20","Select","Select",""],["","59651000305","OMEPRAZOLE ","40MG","30","Select","Select",""],["","65862039010","ONDANSETRON ","4MG ODT","20","Select","Select",""],["","67877032105","IBUPROFEN ","800MG","30","Select","Select",""],["","68382003416","VENLAFAXINE ","37.5 ER","30","Select","Select",""],["","00527147701","DIETHYLPROP ","75MG ER","30","Select","Select",""],["","10702002501","PHENTERMINE ","37.5MG","15","Select","Select",""],["","31722070430","VALACYCLOVIR ","500MG","30","Select","Select",""],["","50428054089","CVS ","5000UNIT","90","Select","Select",""],["","51672129801","KETOCONAZOLE ","2%","15","Select","Select",""],["","00085113204","PROVENTIL ","HFA","7","Select","Select",""],["","00085113204","PROVENTIL","HFA","7","Select","Select",""],["","59651000305","OMEPRAZOLE","40MG","30","Select","Select",""],["","65862039010","ONDANSETRON","4MG ODT","20","Select","Select",""],["","57664012688","HYDROCO\/APAP","5-325MG","20","Select","Select",""],["","62175061743","PANTOPRAZOLE","40MG","60","Select","Select",""],["","67877032105","IBUPROFEN","800MG","30","Select","Select",""],["","68382003416","VENLAFAXINE","37.5 ER","30","Select","Select",""],["","10702002501","PHENTERMINE","37.5MG","15","Select","Select",""],["","50428054089","CVS","5000UNIT","90","Select","Select",""],["","00527147701","DIETHYLPROP","75MG ER","30","Select","Select",""],["","31722070430","VALACYCLOVIR","500MG","30","Select","Select",""],["","51672129801","KETOCONAZOLE","2%","15","Select","Select",""],["","49100040007","CULTURELLE ","CAP ","14","Select","Select",""],["","00093031101","LOPERAMIDE ","CAP 2MG","15","Select","Select",""],["","68180012202","CEPHALEXIN ","CAP 500MG","9","Select","Select",""],["","65862086001","FAMOTIDINE ","TAB 40MG","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":[[["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["Yes","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":""}]}]}