{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ALPHONSA   L JONES","gend":0,"add":"391 TRAILER PARK RD LOT 26","city":"VICTORIA","state":"VA","zip":"23974-9998","dob":"1967-03-07","age":"","mstatus":"","insh":"20030165*01","cliId":"","pno":"434\/321-7642","cno":"434\/321-7642","email":"","ename":"","eno":"","pphy":"ESQUIVEL, MARISSA W MD","ppno":"434\/292-7261","pcpadd":"213 NORTH MAIN ST","pcpcity":"BLACKSTONE","pcpstate":"VA","pcpzip":23824,"pcpcounty":"","pcpid":207852,"pcpname":"BLACKSTONE FAMILY PRACTICE CENTER","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CENTRAL","aligned":"","ano":"434\/480-1878","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/292-7965","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["N18.6","E29.1","L03.90","K52.9","Z09.","I95.89","E11.22","A41.9","E86.1","Z79.4","Z99.2","L02.91","E78.00","I10.","E03.9","M62.830","Z11.59","H16.212","H40.1131","R26.2","E11.42","M79.674","M79.675","B35.1","E11.621","Z91.19","T82.898A","T82.858A","I77.1","I12.0","L03.314","K40.90","L97.529","L97.429","L03.114","N19.","R65.21","K46.9","L97.509","L08.9","Z86.14","G44.209","H04.123","H17.89","H11.89","R79.89","N25.81","D63.1","Z45.2","R60.0","K57.30","M79.604","T82.868A","L72.3","N52.9","M20.41","M20.42","L02.214","L03.115","B95.62","L97.521","G51.0","H40.9","M10.9","E66.9","F33.1","N18.5","E78.2","E11.9","G44.229","F32.9","G47.00","H35.033","H16.042","R68.83","Z74.3","R10.31","G92.","E87.2","Z20.828","K21.9","K40.20","R93.3","E78.5","H53.002","Z01.818","I87.1","H10.402","L73.9"],"date":["2021-08-02","2021-11-19","2020-12-14","2020-12-14","2020-12-14","2020-12-14","2021-08-02","2021-01-04","2020-12-14","2021-03-17","2021-08-02","2021-01-25","2021-04-07","2021-04-07","2021-03-08","2021-08-13","2021-03-08","2021-07-19","2021-05-19","2021-07-28","2021-08-16","2021-08-16","2021-08-16","2021-07-28","2021-08-16","2021-07-28","2021-04-21","2021-04-21","2021-04-21","2021-08-02","2020-12-05","2020-12-05","2020-11-25","2020-11-25","2020-11-25","2020-11-25","2020-12-05","2020-11-28","2020-12-05","2021-03-17","2021-03-17","2021-01-19","2021-05-19","2021-05-19","2021-05-19","2021-07-02","2020-12-03","2020-12-03","2020-11-25","2020-11-25","2020-11-25","2020-11-25","2020-02-21","2021-03-26","2021-03-26","2021-07-28","2021-07-28","2021-01-04","2021-01-04","2021-01-04","2021-01-04","2021-01-04","2021-01-04","2021-01-04","2021-01-04","2020-08-10","2020-01-06","2020-08-10","2020-11-18","2020-01-06","2020-08-10","2020-08-10","2020-11-18","2020-11-18","2020-11-23","2020-11-23","2020-11-23","2020-11-23","2020-11-23","2020-11-23","2021-04-07","2020-11-24","2020-11-24","2021-01-15","2020-12-30","2021-07-02","2020-02-21","2021-04-07","2021-08-13"],"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":[["","58468013001","RENVELA ","800MG","270","Select","Select",""],["","00591352530","LIDOCAINE ","5%","30","Select","Select",""],["","00088221905","LANTUS ","100\/ML","15","Select","Select",""],["","65162010211","GABAPENTIN ","300MG","30","Select","Select",""],["","51991060401","VITAMIN ","50000UNT","4","Select","Select",""],["","62332000291","FAMOTIDINE ","40MG","30","Select","Select",""],["","45802065087","LORATADINE ","10MG","30","Select","Select",""],["","68180035109","SERTRALINE ","25MG","30","Select","Select",""],["","00065026025","TRAVATAN ","0.00%","2","Select","Select",""],["","61442014310","LOVASTATIN ","40MG","30","Select","Select",""],["","65862092127","SEVELAMER ","800MG","300","Select","Select",""],["","00115423301","MIDODRINE ","10MG","30","Select","Select",""],["","00781618556","TRAVOPROST ","0.00%","2","Select","Select",""],["","68382009205","CARVEDILOL ","3.125MG","60","Select","Select",""],["","16729013616","CLONAZEPAM ","0.5MG","40","Select","Select",""],["","00574082710","TESTOST ","200MG\/ML","10","Select","Select",""],["","13668000805","ZOLPIDEM ","10MG","30","Select","Select",""],["","00023920515","REFRESH ","1% OP","15","Select","Select",""],["","65862056099","PANTOPRAZOLE ","40MG","30","Select","Select",""],["","67877032105","IBUPROFEN ","800MG","20","Select","Select",""],["","13668015510","ESOMEPRA ","40MG DR","30","Select","Select",""],["","10702000601","CYCLOBENZAPR ","5MG","30","Select","Select",""],["","60258016101","RENA-VITE ","","30","Select","Select",""],["","64380088404","CINACALCET ","60MG","30","Select","Select",""],["","08290309575","3ML ","21GX1\"","6","Select","Select",""],["","64764017530","DEXILANT ","60MG DR","30","Select","Select",""],["","23155013525","DOXYCYC ","100MG","20","Select","Select",""],["","68382089906","TADALAFIL ","20MG","5","Select","Select",""],["","51660052601","ALLERGY ","10MG","30","Select","Select",""],["","47781023005","OXYCOD\/APAP ","10-325MG","20","Select","Select",""],["","00781261305","AMOXICILLIN ","500MG","21","Select","Select",""],["","67877041920","LINEZOLID ","600MG","28","Select","Select",""],["","10542007010","DIALYVITE ","800","90","Select","Select",""],["","58790000030","THERATEARS ","0.25% PF","30","Select","Select",""],["","00603233832","APAP\/CODEINE ","300-30MG","10","Select","Select",""],["","00065064705","TOBRADEX ","0.3-0.1%","5","Select","Select",""],["","16571041250","CIPROFLOXACN ","500MG","28","Select","Select",""],["","08290320109","BD  PEN NEEDL","31GX8MM","100","Select","Select",""],["","42571025201","CLINDAMYCIN ","300MG","30","Select","Select",""],["","51672131200","MUPIROCIN ","2%","22","Select","Select",""],["","60758090810","POLYMYXIN ","TRIMETHP","10","Select","Select",""],["","64980051501","OFLOXACIN ","0.3% OP","10","Select","Select",""],["","24208029505","TOBRA\/DEXAME ","0.3-0.1%","5","Select","Select",""],["","24208091055","ERYTHROMYCIN ","5MG\/GM","4","Select","Select",""],["","00023587901","NEPHRO-VITE ","RX","30","Select","Select",""],["","45802065087","LORATADINE","10MG","30","Select","Select",""],["","00065026025","TRAVATAN","0.00%","2","Select","Select",""],["","61442014310","LOVASTATIN","40MG","30","Select","Select",""],["","62332000291","FAMOTIDINE","40MG","30","Select","Select",""],["","51991060401","VITAMIN","50000UNT","4","Select","Select",""],["","68180035109","SERTRALINE","25MG","30","Select","Select",""],["","58468013001","RENVELA","800MG","270","Select","Select",""],["","00591352530","LIDOCAINE","5%","30","Select","Select",""],["","13668000710","ZOLPIDEM","5MG","30","Select","Select",""],["","67877022310","GABAPENTIN","300MG","30","Select","Select",""],["","00115423301","MIDODRINE","10MG","30","Select","Select",""],["","16729013616","CLONAZEPAM","0.5MG","40","Select","Select",""],["","68382009205","CARVEDILOL","3.125MG","60","Select","Select",""],["","00023920515","REFRESH","1% OP","15","Select","Select",""],["","65862092127","SEVELAMER","800MG","300","Select","Select",""],["","00781618556","TRAVOPROST","0.00%","2","Select","Select",""],["","00088221905","LANTUS","100\/ML","15","Select","Select",""],["","00574082710","TESTOST","200MG\/ML","10","Select","Select",""],["","64764017530","DEXILANT","60MG DR","30","Select","Select",""],["","65862056099","PANTOPRAZOLE","40MG","30","Select","Select",""],["","13668015510","ESOMEPRA","40MG DR","30","Select","Select",""],["","08290309575","3ML","21GX1\"","6","Select","Select",""],["","51660052601","ALLERGY","10MG","30","Select","Select",""],["","68382089906","TADALAFIL","20MG","5","Select","Select",""],["","47781023005","OXYCOD\/APAP","10-325MG","20","Select","Select",""],["","00603233832","APAP\/CODEINE","300-30MG","10","Select","Select",""],["","10702000601","CYCLOBENZAPR","5MG","30","Select","Select",""],["","67877032105","IBUPROFEN","800MG","20","Select","Select",""],["","16571041250","CIPROFLOXACN","500MG","28","Select","Select",""],["","08290320109","BD PEN NEEDL","31GX8MM","100","Select","Select",""],["","42571025201","CLINDAMYCIN","300MG","30","Select","Select",""],["","00713055593","DOXYCYC","100MG","20","Select","Select",""],["","58790000030","THERATEARS","0.25% PF","30","Select","Select",""],["","60258016101","RENA-VITE","","30","Select","Select",""],["","64980051501","OFLOXACIN","0.3% OP","10","Select","Select",""],["","51672131200","MUPIROCIN","2%","22","Select","Select",""],["","64380088404","CINACALCET","60MG","30","Select","Select",""],["","60758090810","POLYMYXIN","TRIMETHP","10","Select","Select",""],["","00023587901","NEPHRO-VITE","RX","30","Select","Select",""],["","24208091055","ERYTHROMYCIN","5MG\/GM","7","Select","Select",""],["","24208029505","TOBRA\/DEXAME","0.3-0.1%","5","Select","Select",""],["","10542007010","DIALYVITE","800","90","Select","Select",""],["","00781261305","AMOXICILLIN","500MG","21","Select","Select",""],["","67877041920","LINEZOLID","600MG","28","Select","Select",""],["","00065064705","TOBRADEX","0.3-0.1%","5","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","",""],["Yes","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":""}]}]}