{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"VERN  D JACKSON","gend":0,"add":"353 W 49TH ST","city":"RICHMOND","state":"VA","zip":"23225-9998","dob":"1964-03-11","age":"","mstatus":"","insh":"20047477*01","cliId":"","pno":"804\/683-3195","cno":"804\/683-3195","email":"","ename":"","eno":"","pphy":"MCCONNELL, AMY C MD","ppno":"804\/560-8838","pcpadd":"SUITE 1-A 9220 FOREST HILL AVE","pcpcity":"RICHMOND","pcpstate":"VA","pcpzip":23235,"pcpcounty":"","pcpid":168330,"pcpname":"COMMONWEALTH INTERNAL MEDICINE ASSOCIATES","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CENTRAL","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"804\/560-3527","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["J32.4","I10.","K21.9","R79.0","Z59.0","Z68.25","N17.8","E87.2","T39.1X1A","K76.9","K82.8","N17.0","G93.40","D68.9","E46.","R18.8","K71.10","T51.0X1A","F10.20","E86.0","E87.5","E83.39","E83.42","E87.6","I25.10","Z99.2","F10.10","I44.0","K72.00","I95.9","E16.2","N17.9","I35.8"],"date":["2020-01-13","2021-08-08","2020-01-23","2020-01-23","2020-01-23","2020-01-23","2021-08-13","2021-08-09","2021-08-12","2021-08-17","2021-08-17","2021-08-08","2021-08-08","2021-08-08","2021-08-08","2021-08-08","2021-08-08","2021-08-08","2021-08-08","2021-08-08","2021-08-08","2021-08-14","2021-08-14","2021-08-14","2021-08-08","2021-08-11","2021-08-12","2021-08-08","2021-08-08","2021-08-08","2021-08-08","2021-08-08","2021-08-09"],"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":[["","00378235193","ESOMEPRA ","40MG DR","30","Select","Select",""],["","68180072103","AMLODIPINE ","10MG","30","Select","Select",""],["","59651000305","OMEPRAZOLE ","40MG","30","Select","Select",""],["","17478010002","CYCLOPENTOL ","1% OP","4","Select","Select",""],["","59779060006","CVS ","81MG EC","30","Select","Select",""],["","68180098103","LISINOPRIL ","20MG","30","Select","Select",""],["","00603188016","LIDOCAINE ","5%","30","Select","Select",""],["","00065039605","CYCLOGYL ","1% OP","5","Select","Select",""],["","50383077932","LACTULOSE ","10GM\/15","900","Select","Select",""],["","00536123441","ASPIRIN ","81MG EC","30","Select","Select",""],["","80681005000","DAILY-VITE ","","30","Select","Select",""],["","65162036111","FOLIC ","1MG","30","Select","Select",""],["","00603020922","MAG ","400MG","120","Select","Select",""],["","80681002000","MULTIVITAMIN ","","30","Select","Select",""],["","10135013201","THIAMINE ","100MG","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":[[["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":""}]}]}