{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JOHN   F DAVIS","gend":0,"add":"63 S COBBLESTONE CT","city":"FISHERSVILLE","state":"VA","zip":"22939-9998","dob":"1959-07-06","age":"","mstatus":"","insh":"20026243*01","cliId":"","pno":"540\/256-7883","cno":"540\/256-7883","email":"","ename":"","eno":"","pphy":"MARTINEZ, ANTHONY MD","ppno":"434\/823-4567","pcpadd":"1646 PARK RIDGE DRIVE","pcpcity":"CROZET","pcpstate":"VA","pcpzip":22932,"pcpcounty":"","pcpid":145518,"pcpname":"SMJMG - Sentara Crozet Family Medicine","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/823-4272","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M54.42","Z79.899","R52.","R22.30","R22.31","M54.41","G89.29","F17.210","Z12.2","M47.816","M54.5","Z72.0","Z86.010","D12.3","K57.30","K44.9","R10.84","K21.9","M25.512","M25.522","R22.32","R07.89","S22.32XA","M54.16","S46.002A","K57.90","Z79.891","G89.4","R63.0","Z87.19","K63.5"],"date":["2021-09-15","2020-11-24","2020-03-09","2020-02-13","2020-02-13","2021-09-15","2021-09-15","2020-12-07","2020-12-07","2021-09-15","2021-05-12","2020-12-07","2020-11-03","2020-11-03","2020-11-03","2020-11-24","2020-11-03","2020-11-24","2020-06-08","2020-06-03","2020-06-03","2020-12-29","2020-12-29","2021-02-04","2020-06-08","2020-11-24","2021-05-12","2021-05-12","2020-10-20","2020-10-20","2020-10-20"],"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":[["","00406012305","HYDROCO\/APAP ","5-325MG","90","Select","Select",""],["","13668000810","ZOLPIDEM ","10MG","30","Select","Select",""],["","00591352530","LIDOCAINE ","5%","30","Select","Select",""],["","62175061743","PANTOPRAZOLE ","40MG","30","Select","Select",""],["","69097081312","GABAPENTIN ","100MG","90","Select","Select",""],["","52268010001","GOLYTELY ","","4000","Select","Select",""],["","42858010201","OXYCOD\/APAP ","5-325MG","90","Select","Select",""],["","69547035302","NARCAN ","","2","Select","Select",""],["","00378912198","FENTANYL ","25MCG\/HR","10","Select","Select",""],["","72853005102","NALOXONE ","2MG","1","Select","Select",""],["","63481062370","PERCOCET ","5-325MG","90","Select","Select",""],["","10572030201","PEG-3350\/KCL ","\/SODIUM","4000","Select","Select",""],["","00378064110","PREDNISONE ","10MG","52","Select","Select",""],["","10572010101","PEG-3350 ","ELECTROL","4000","Select","Select",""],["","52268001201","SUPREP ","PREP KIT","354","Select","Select",""],["","63481068706","LIDODERM ","5%","30","Select","Select",""],["","13668000810","ZOLPIDEM","10MG","30","Select","Select",""],["","00406012305","HYDROCO\/APAP","5-325MG","90","Select","Select",""],["","00591352530","LIDOCAINE","5%","30","Select","Select",""],["","42858010201","OXYCOD\/APAP","5-325MG","90","Select","Select",""],["","13668042990","PANTOPRAZOLE","40MG","30","Select","Select",""],["","69547035302","NARCAN","","2","Select","Select",""],["","72853005102","NALOXONE","2MG","1","Select","Select",""],["","69097081312","GABAPENTIN","100MG","90","Select","Select",""],["","63481062370","PERCOCET","5-325MG","90","Select","Select",""],["","10572010101","PEG-3350","ELECTROL","4000","Select","Select",""],["","52268010001","GOLYTELY","","4000","Select","Select",""],["","10572030201","PEG-3350\/KCL","\/SODIUM","4000","Select","Select",""],["","00378064110","PREDNISONE","10MG","52","Select","Select",""],["","52268001201","SUPREP","PREP KIT","354","Select","Select",""],["","00378912198","FENTANYL","25MCG\/HR","10","Select","Select",""],["","63481068706","LIDODERM","5%","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","",""],["N\/A","Select","","","","","Select","",""],["Yes","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":""}]}]}