{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"HAZEL TURNER","gend":1,"add":"65 W CLOPTON ST ST FRANCIS HOME","city":"RICHMOND","state":"VA","zip":"23225-9998","dob":"1954-03-23","age":"","mstatus":"","insh":"20045124*01","cliId":"","pno":"804\/253-3213","cno":"804\/253-3213","email":"","ename":"","eno":"","pphy":"JOSEPH, LERLA G MD","ppno":"804\/230-4913","pcpadd":"1606 HULL ST RD","pcpcity":"RICHMOND","pcpstate":"VA","pcpzip":23224,"pcpcounty":"","pcpid":105617,"pcpname":"","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CENTRAL","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"804\/233-1841","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E11.9","I10.","F31.9","G31.84","B20.","Z79.4","Z87.891","Z79.899","M54.5","K76.0","R42.","F20.9","C50.811","Z17.0","R92.1","C50.911","J45.909","Z23.","Z79.84","NO DATA","K75.81","R19.7","F41.9"],"date":["2021-05-06","2021-05-06","2021-03-04","2020-07-29","2021-06-29","2021-05-06","2021-05-06","2021-05-06","2021-05-06","2021-05-06","2021-05-06","2021-08-23","2021-06-29","2021-06-29","2021-07-15","2021-07-15","2020-07-29","2020-01-08","2020-02-25","2021-06-18","2020-07-29","2021-01-30","2021-01-30"],"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":[["","61442010310","DICLOFENAC ","75MG DR","58","Select","Select",""],["","68382011505","RISPERIDONE ","2MG","29","Select","Select",""],["","13668011310","LOSARTAN ","25MG","30","Select","Select",""],["","00904641292","CALC ","500MG","60","Select","Select",""],["","62756079713","DIVALPROEX ","250MG DR","87","Select","Select",""],["","62332000191","FAMOTIDINE ","20MG","29","Select","Select",""],["","00088222033","LANTUS ","100\/ML","10","Select","Select",""],["","43547027511","DONEPEZIL ","5MG","29","Select","Select",""],["","49702023113","TRIUMEQ ","","30","Select","Select",""],["","00603243832","BENZTROPINE ","1MG","58","Select","Select",""],["","00591352530","LIDOCAINE ","5%","30","Select","Select",""],["","67877056110","METFORMIN ","500MG","124","Select","Select",""],["","08290329515","AUTOSHIELD ","30GX5MM","100","Select","Select",""],["","45963053830","ONDANSETRON ","4MG","20","Select","Select",""],["","57896010210","ACETAMINOPHE ","325MG","30","Select","Select",""],["","00169750111","NOVOLOG ","100\/ML","10","Select","Select",""],["","56151147002","TRUE ","METER","1","Select","Select",""],["","67877019710","AMLODIPINE ","2.5MG","30","Select","Select",""],["","08222092595","INSULIN ","0.5\/29G","100","Select","Select",""],["","33332032002","AFLURIA ","2020-21","0","Select","Select",""],["","08271036100","LANCETS ","THIN","100","Select","Select",""],["","63739044001","ACETAMIN ","325MG","30","Select","Select",""],["","00904651661","MECLIZINE ","12.5MG","20","Select","Select",""],["","59267100002","PFIZER ","COVID-19","0","Select","Select",""],["","00904615760","VITAMIN ","2000UNIT","23","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":""}]}]}