{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"KELNISHA   B GRICE","gend":1,"add":"943 16TH ST","city":"NEWPORT NEWS","state":"VA","zip":"23607-9998","dob":"1996-11-25","age":"","mstatus":"","insh":"2051716*01","cliId":"","pno":"757\/690-3174","cno":"757\/690-3174","email":"","ename":"","eno":"","pphy":"BAINES, ROBIN S MD","ppno":"757\/726-5000","pcpadd":"200 EATON ST","pcpcity":"HAMPTON","pcpstate":"VA","pcpzip":23669,"pcpcounty":"","pcpid":101284,"pcpname":"SMG - Sentara Family & Internal Medicine Physicians - Williamsburg","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/726-5001","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["O34.211","Z3A.39","Z37.0","G43.009","L03.011","Z34.83","Z3A.37","K90.0","L30.9","L72.9","Z71.9","R00.2","K21.9","K58.1","O00.80","R21.","O99.354","O99.02","D57.3","G43.909","O26.893","Z67.91","Z79.899","Z91.040","Z82.79","Z80.3","Z80.49","Z82.69","O34.219","Z3A.00","F41.9","F43.9","N76.0","O20.0","Z3A.01","B37.3","R26.89","M54.41","E55.9","R10.13","R10.33","R11.0","R51.9","K52.9","B37.9","T36.95XA","Z34.93","Z3A.38","R20.2","Z31.82","Z39.1","Z20.828","N93.9","R10.2","Z13.9","N93.8","R10.84","O03.9","Z20.822","O00.90","Z87.891","R06.02","L02.412"],"date":["2020-03-17","2020-03-17","2020-03-17","2020-12-29","2020-10-24","2020-03-05","2020-03-05","2020-09-04","2020-12-09","2020-12-09","2020-12-09","2021-06-09","2021-06-09","2021-06-09","2021-07-18","2021-07-19","2020-03-17","2020-03-17","2020-08-19","2020-03-17","2020-03-17","2020-03-17","2021-09-07","2021-09-07","2020-03-17","2020-03-17","2020-03-17","2020-03-17","2020-03-17","2020-03-17","2020-08-19","2020-07-23","2021-01-15","2021-07-06","2021-07-06","2021-07-16","2020-06-29","2020-06-29","2020-08-19","2020-08-20","2020-08-20","2020-08-20","2020-12-29","2020-09-17","2020-10-21","2020-10-21","2020-03-12","2020-03-12","2020-12-29","2021-03-24","2020-03-13","2020-10-18","2021-08-01","2021-08-01","2021-07-18","2021-08-06","2021-08-06","2021-08-15","2021-07-09","2021-09-07","2021-09-07","2021-08-29","2021-09-07"],"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":[["","51991036378","RIZATRIPTAN ","10MG ODT","12","Select","Select",""],["","67877032105","IBUPROFEN ","800MG","30","Select","Select",""],["","00536106210","STOOL ","100MG","20","Select","Select",""],["","69097012203","TOPIRAMATE ","25MG","60","Select","Select",""],["","62175018046","PANTOPRAZOLE ","20MG","30","Select","Select",""],["","68462010530","ONDANSETRON ","4MG","21","Select","Select",""],["","55111015810","OMEPRAZOLE ","20MG","90","Select","Select",""],["","13668013601","ESCITALOPRAM ","10MG","90","Select","Select",""],["","50383077504","LIDOCAINE ","2% VISC","100","Select","Select",""],["","00093221001","SUCRALFATE ","1GM","20","Select","Select",""],["","33342032915","TRIAMCINOLON ","0.10%","15","Select","Select",""],["","69452015120","VITAMIN ","50000UNT","12","Select","Select",""],["","70710113908","FLUCONAZOLE ","150MG","2","Select","Select",""],["","65862050220","AMOX\/K ","500-125","30","Select","Select",""],["","50111033401","METRONIDAZOL ","500MG","14","Select","Select",""],["","68180065208","DOXYCYC ","100MG","20","Select","Select",""],["","71930005552","APAP\/CODEINE ","300-30MG","30","Select","Select",""],["","00116200116","CHLORHEX ","0.12%","473","Select","Select",""],["","68180095604","CLOBETASOL ","0.05%","60","Select","Select",""],["","51672404806","CLOTRIM\/BETA ","DIPROP","45","Select","Select",""],["","00472173803","MICONAZOLE ","200MG","9","Select","Select",""],["","67877032105","IBUPROFEN","800MG","30","Select","Select",""],["","00536106210","STOOL","100MG","20","Select","Select",""],["","51991036378","RIZATRIPTAN","10MG ODT","12","Select","Select",""],["","13668013601","ESCITALOPRAM","10MG","90","Select","Select",""],["","55111015810","OMEPRAZOLE","20MG","90","Select","Select",""],["","00093221001","SUCRALFATE","1GM","20","Select","Select",""],["","33342032915","TRIAMCINOLON","0.10%","15","Select","Select",""],["","50383077504","LIDOCAINE","2% VISC","100","Select","Select",""],["","68462010530","ONDANSETRON","4MG","11","Select","Select",""],["","70710113908","FLUCONAZOLE","150MG","2","Select","Select",""],["","65862050220","AMOX\/K","500-125","30","Select","Select",""],["","50111033401","METRONIDAZOL","500MG","14","Select","Select",""],["","68180065208","DOXYCYC","100MG","20","Select","Select",""],["","71930005552","APAP\/CODEINE","300-30MG","30","Select","Select",""],["","68180095604","CLOBETASOL","0.05%","60","Select","Select",""],["","00116200116","CHLORHEX","0.12%","473","Select","Select",""],["","69097012203","TOPIRAMATE","25MG","60","Select","Select",""],["","00472173803","MICONAZOLE","200MG","9","Select","Select",""],["","63304069301","CLINDAMYCIN","300MG","28","Select","Select",""],["","51672404806","CLOTRIM\/BETA","DIPROP","45","Select","Select",""],["","62175018046","PANTOPRAZOLE","20MG","30","Select","Select",""],["","69452015120","VITAMIN","50000UNT","12","Select","Select",""],["","53746010901","HYDROCO\/APAP","5-325MG","15","Select","Select",""],["","45802012801","CLINDAMYCIN ","LOT 0.01","60","Select","Select",""],["","53746010901","HYDROCO\/APAP ","TAB 5-325MG","15","Select","Select",""],["","00093321992","KETOCONAZOLE ","CRE 0.02","60","Select","Select",""],["","50428041363","ACNE ","CRE CVS CONT","142","Select","Select",""],["","00234057508","HIBICLENS ","LIQ 0.04","236","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","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["No","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":""}]}]}