{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"RONNIE   J GOODE","gend":0,"add":"1104 FILLMORE ST APT 3","city":"LYNCHBURG","state":"VA","zip":"24501-9998","dob":"1966-11-16","age":"","mstatus":"","insh":"20048088*01","cliId":"","pno":"434\/420-5080","cno":"434\/420-5080","email":"","ename":"","eno":"","pphy":"","ppno":"","pcpadd":"","pcpcity":"","pcpstate":"","pcpzip":"","pcpcounty":"","pcpid":"","pcpname":"","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R10.32","R07.9","R19.7","R11.2","F17.210","K04.7","R06.89","R11.0","I10.","R51.9","D57.1","Z79.899","Z86.69","H66.90","K02.9","D51.9","NO DATA","K08.89","R56.9","K21.9","F32.9","Z20.828","Y04.8XXA","W19.XXXA","R53.81","B34.9","R06.2","S09.90XA","J43.9","M25.561","Y92.89"],"date":["2020-10-13","2020-10-13","2020-10-13","2020-10-13","2020-10-21","2020-10-30","2020-10-30","2020-03-17","2021-06-04","2020-10-21","2020-10-21","2020-10-21","2020-10-21","2020-01-15","2020-01-15","2020-01-15","2020-01-15","2020-10-14","2020-10-14","2020-10-14","2020-10-14","2020-10-14","2021-06-04","2021-06-04","2021-06-04","2020-02-22","2020-02-22","2021-06-04","2021-06-04","2021-06-04","2021-06-04"],"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":[["","00000000000000000000","","","90","Select","Select",""],["","60505082901","FLUTICASONE ","50MCG","16","Select","Select",""],["","67877019810","AMLODIPINE ","5MG","30","Select","Select",""],["","00093031101","LOPERAMIDE ","2MG","90","Select","Select",""],["","29300022705","METRONIDAZOL ","500MG","14","Select","Select",""],["","24208029505","TOBRA\/DEXAME ","0.3-0.1%","5","Select","Select",""],["","00536355101","VITAMIN ","500MCG","90","Select","Select",""],["","57664080888","PHENYTOIN ","100MG","90","Select","Select",""],["","43547035411","LISINOPRIL ","20MG","30","Select","Select",""],["","69618001010","ACETAMIN ","325MG","20","Select","Select",""],["","65862018730","ONDANSETRON ","4MG","8","Select","Select",""],["","00591079510","DICYCLOMINE ","20MG","120","Select","Select",""],["","43547028110","ESCITALOPRAM ","10MG","30","Select","Select",""],["","55111015810","OMEPRAZOLE ","20MG","30","Select","Select",""],["","00904681546","MUCUS ","400MG","60","Select","Select",""],["","57237004105","PENICILLN ","500MG","28","Select","Select",""],["","65862001501","AMOXICILLIN ","875MG","14","Select","Select",""],["","29300022705","METRONIDAZOL","500MG","14","Select","Select",""],["","24208029505","TOBRA\/DEXAME","0.3-0.1%","5","Select","Select",""],["","00536355101","VITAMIN","500MCG","90","Select","Select",""],["","00093031101","LOPERAMIDE","2MG","90","Select","Select",""],["","69618001010","ACETAMIN","325MG","20","Select","Select",""],["","43547035411","LISINOPRIL","20MG","30","Select","Select",""],["","65862018730","ONDANSETRON","4MG","8","Select","Select",""],["","55111015810","OMEPRAZOLE","20MG","30","Select","Select",""],["","00904681546","MUCUS","400MG","60","Select","Select",""],["","60505082901","FLUTICASONE","50MCG","16","Select","Select",""],["","67877019810","AMLODIPINE","5MG","30","Select","Select",""],["","00591079510","DICYCLOMINE","20MG","120","Select","Select",""],["","65862001501","AMOXICILLIN","875MG","14","Select","Select",""],["","43547028111","ESCITALOPRAM","10MG","28","Select","Select",""],["","57237004105","PENICILLN","500MG","28","Select","Select",""],["","57664080818","PHENYTOIN","100MG","84","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","",""],["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":""}]}]}