{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JULIA CREWS","gend":1,"add":"636 18TH ST","city":"NEWPORT NEWS","state":"VA","zip":"23607-9998","dob":"1981-01-28","age":"","mstatus":"","insh":"1271214*01","cliId":"","pno":"757\/713-0508","cno":"757\/713-0508","email":"","ename":"","eno":"","pphy":"BAINES, ROBIN S MD","ppno":"757\/726-5000","pcpadd":"200 EATON ST","pcpcity":"HAMPTON","pcpstate":"VA","pcpzip":23669,"pcpcounty":"","pcpid":101284,"pcpname":"SMG - Sentara Family & Internal Medicine Physicians - Williamsburg","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"757\/268-9950","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/726-5001","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["N39.0","R11.2","R10.9","R19.7","D50.9","R39.9","Z68.44","R53.82","F41.0","R10.13","F41.9","F51.05","E55.9","Z98.84","D50.8","G89.29","D72.829","Z01.818","K90.9","K21.9","Z68.43","J01.90","N30.00","Z11.3","B37.3","N95.1","L25.8","L08.9","A59.9","H66.90","J06.9","B96.20","J02.9","Z20.822","A74.9"],"date":["2021-07-15","2020-11-04","2020-11-04","2020-11-04","2020-11-04","2020-07-31","2020-07-31","2020-11-03","2020-09-04","2020-07-31","2020-11-03","2020-07-31","2020-07-31","2020-11-03","2021-04-01","2020-07-31","2021-04-01","2020-10-31","2020-11-16","2020-11-16","2020-11-16","2021-07-20","2020-05-07","2020-09-04","2020-09-04","2020-11-03","2021-04-30","2021-04-30","2021-07-20","2021-07-20","2021-07-15","2021-07-15","2021-07-20","2021-07-20","2021-07-20"],"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":[["","58657050016","CODEINE\/GG ","10-100\/5","120","Select","Select",""],["","24658031205","DOXYCYCL ","100MG","14","Select","Select",""],["","00093317431","ALBUTEROL ","HFA","8","Select","Select",""],["","65862042005","SMZ\/TMP ","800-160","10","Select","Select",""],["","65162074510","PROMETHAZINE ","12.5MG","60","Select","Select",""],["","43199001401","HYOSCYAMINE ","0.375 ER","30","Select","Select",""],["","68180012202","CEPHALEXIN ","500MG","14","Select","Select",""],["","00143122701","DICYCLOMINE ","20MG","120","Select","Select",""],["","00054350049","LIDOCAINE ","2% VISC","100","Select","Select",""],["","14539067501","HYDROXYZ ","50MG","120","Select","Select",""],["","00536100901","FERROUS ","325MG","30","Select","Select",""],["","60505036302","OFLOXACIN ","0.3%OTIC","10","Select","Select",""],["","71930002643","BROM\/PSE\/DM ","","236","Select","Select",""],["","65862001501","AMOXICILLIN ","875MG","20","Select","Select",""],["","65862056090","PANTOPRAZOLE ","40MG","20","Select","Select",""],["","70710113908","FLUCONAZOLE ","150MG","1","Select","Select",""],["","16729020201","BUSPIRONE ","10MG","90","Select","Select",""],["","43386005019","GAVILYTE-N ","FLAV PK","4000","Select","Select",""],["","00713052612","PROMETHEGAN ","25MG","12","Select","Select",""],["","68382003416","VENLAFAXINE ","37.5 ER","60","Select","Select",""],["","59762040101","SUCRALFATE ","1GM","90","Select","Select",""],["","62175011843","OMEPRAZOLE ","20MG","30","Select","Select",""],["","00054327099","FLUTICASONE ","50MCG","16","Select","Select",""],["","00781808926","AZITHROMYCIN ","250MG","6","Select","Select",""],["","55111029236","SUMATRIPTAN ","50MG","5","Select","Select",""],["","53100020215","FLONASE ","27.5MCG","18","Select","Select",""],["","00378064205","PREDNISONE ","20MG","15","Select","Select",""],["","50111033401","METRONIDAZOL ","500MG","14","Select","Select",""],["","68462010530","ONDANSETRON ","4MG","12","Select","Select",""],["","47781030801","NITROFUR ","100MG","10","Select","Select",""],["","00093101042","MUPIROCIN ","2%","22","Select","Select",""],["","67877057305","BENZONATATE ","100MG","45","Select","Select",""],["","00093317431","ALBUTEROL","HFA","8","Select","Select",""],["","24658031205","DOXYCYCL","100MG","14","Select","Select",""],["","58657050016","CODEINE\/GG","10-100\/5","120","Select","Select",""],["","65862042005","SMZ\/TMP","800-160","10","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","14","Select","Select",""],["","00536100901","FERROUS","325MG","30","Select","Select",""],["","16729020201","BUSPIRONE","10MG","90","Select","Select",""],["","70710113908","FLUCONAZOLE","150MG","1","Select","Select",""],["","14539067501","HYDROXYZ","50MG","120","Select","Select",""],["","43199001401","HYOSCYAMINE","0.375 ER","30","Select","Select",""],["","43386005019","GAVILYTE-N","FLAV PK","4000","Select","Select",""],["","00713052612","PROMETHEGAN","25MG","12","Select","Select",""],["","10702000350","PROMETHAZINE","25MG","12","Select","Select",""],["","65862056090","PANTOPRAZOLE","40MG","20","Select","Select",""],["","00591079401","DICYCLOMINE","10MG","20","Select","Select",""],["","62175011843","OMEPRAZOLE","20MG","30","Select","Select",""],["","68382003416","VENLAFAXINE","37.5 ER","60","Select","Select",""],["","59762040101","SUCRALFATE","1GM","90","Select","Select",""],["","00054350049","LIDOCAINE","2% VISC","100","Select","Select",""],["","00781808926","AZITHROMYCIN","250MG","6","Select","Select",""],["","60505082901","FLUTICASONE","50MCG","16","Select","Select",""],["","00093101042","MUPIROCIN","2%","22","Select","Select",""],["","53100020215","FLONASE","27.5MCG","18","Select","Select",""],["","71930002643","BROM\/PSE\/DM","","118","Select","Select",""],["","60505036302","OFLOXACIN","0.3%OTIC","10","Select","Select",""],["","65862001501","AMOXICILLIN","875MG","20","Select","Select",""],["","47781030801","NITROFUR","100MG","10","Select","Select",""],["","67877057305","BENZONATATE","100MG","45","Select","Select",""],["","50111033401","METRONIDAZOL","500MG","14","Select","Select",""],["","68462010530","ONDANSETRON","4MG","12","Select","Select",""],["","55111029236","SUMATRIPTAN","50MG","5","Select","Select",""],["","00378064205","PREDNISONE","20MG","15","Select","Select",""],["","75826011410","PHENAZOPYRID ","TAB 100MG","10","Select","Select",""],["","65162019050","NAPROXEN ","TAB 500MG","20","Select","Select",""],["","65862067899","ALPRAZOLAM ","TAB 1MG","30","Select","Select",""],["","69097084507","CYCLOBENZAPR ","TAB 5MG","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":[[["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["No","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":""}]}]}