{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ELELLA   V BRAUN","gend":1,"add":"3514 FLOYD AVE APT 1","city":"RICHMOND","state":"VA","zip":"23221-9998","dob":"1948-08-30","age":"","mstatus":"","insh":"20040483*01","cliId":"","pno":"804-358-3935","cno":"804-358-3935","email":"","ename":"","eno":"","pphy":"JACKSON, RICHARD A MD","ppno":"804\/225-7148","pcpadd":"304 E LEIGH ST","pcpcity":"RICHMOND","pcpstate":"VA","pcpzip":23219,"pcpcounty":"","pcpid":105660,"pcpname":"Dominion Medical Associates, INC.","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CENTRAL","aligned":"","ano":"804-353-0676","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"804\/225-7159","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["H25.22","V54.16","E87.1","I12.9","E11.22","N18.9","E11.65","E11.42","E11.9","L85.9","B35.1","I63.30","E78.2","I63.9","H25.21","M21.6X1","M21.6X2","R27.8","R26.89","M21.371","I63.419","L89.159","M79.671","R94.31","I11.9"],"date":["2020-05-20","2020-01-15","2020-01-07","2020-01-07","2021-04-01","2020-01-07","2020-01-07","2021-07-09","2020-07-31","2021-07-09","2021-07-09","2021-04-01","2021-04-01","2021-04-01","2020-03-04","2020-07-31","2020-07-31","2020-04-29","2020-07-31","2020-04-29","2020-07-31","2020-07-15","2020-01-15","2021-08-25","2021-08-25"],"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":[["","08290320109","BD  PEN NEEDL","31GX8MM","100","Select","Select",""],["","16729018201","HYDROCHLOROT ","12.5MG","30","Select","Select",""],["","65862020390","LOSARTAN ","100MG","90","Select","Select",""],["","68180072003","AMLODIPINE ","5MG","90","Select","Select",""],["","62175061743","PANTOPRAZOLE ","40MG","90","Select","Select",""],["","70436009205","ASA\/DIPYRIDA ","25-200MG","60","Select","Select",""],["","70377002911","ATORVASTATIN ","40MG","30","Select","Select",""],["","00088221905","LANTUS ","100\/ML","6","Select","Select",""],["","61314063710","PREDNISOLONE ","1% OP","10","Select","Select",""],["","60505056000","OFLOXACIN ","0.3% OP","5","Select","Select",""],["","60758077305","KETOROLAC ","0.40%","5","Select","Select",""],["","13668025330","OLM ","40-25MG","90","Select","Select",""],["","00093321915","KETOCONAZOLE ","2%","30","Select","Select",""],["","00093031101","LOPERAMIDE ","2MG","120","Select","Select",""],["","45802041926","AMMONIUM ","12%","400","Select","Select",""],["","45802014167","CICLOPIROX ","8%","7","Select","Select",""],["","00904615760","VITAMIN ","2000UNIT","70","Select","Select",""],["","49281012065","FLUZONE ","PF 20-21","1","Select","Select",""],["","00193709021","CONTOUR ","BLD GLUC","100","Select","Select",""],["","62175061743","PANTOPRAZOLE","40MG","30","Select","Select",""],["","68180072003","AMLODIPINE","5MG","90","Select","Select",""],["","70436009205","ASA\/DIPYRIDA","25-200MG","60","Select","Select",""],["","08290320109","BD PEN NEEDL","31GX8MM","100","Select","Select",""],["","70377002911","ATORVASTATIN","40MG","30","Select","Select",""],["","65862020390","LOSARTAN","100MG","30","Select","Select",""],["","16729018201","HYDROCHLOROT","12.5MG","30","Select","Select",""],["","00093031101","LOPERAMIDE","2MG","120","Select","Select",""],["","00088221905","LANTUS","100\/ML","15","Select","Select",""],["","60505056000","OFLOXACIN","0.3% OP","5","Select","Select",""],["","61314063710","PREDNISOLONE","1% OP","10","Select","Select",""],["","60758077305","KETOROLAC","0.40%","5","Select","Select",""],["","00093321915","KETOCONAZOLE","2%","30","Select","Select",""],["","45802041926","AMMONIUM","12%","400","Select","Select",""],["","45802014167","CICLOPIROX","8%","7","Select","Select",""],["","13668025330","OLM","40-25MG","90","Select","Select",""],["","00904615760","VITAMIN","2000UNIT","70","Select","Select",""],["","49281012065","FLUZONE","PF 20-21","1","Select","Select",""],["","00193709021","CONTOUR","BLD GLUC","100","Select","Select",""],["","70461012103","FLUAD ","INJ 2021-22","0","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":""}]}]}