{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"RAFAELA TORRES","gend":1,"currentgend":"","add":"717 E Campus St","city":"Wichita","state":"KS","zip":"67216","age":"","mstatus":"","insh":"K44008142","cliId":"","pno":"3162137417","cno":"","email":"","ename":"","eno":"","pphy":"KATHY NGUYEN","ppno":"3166895500","pcpadd":"1121 S CLIFTON","pcpcity":"WICHITA","pcpstate":"KS","pcpzip":"67218-2912","pcpcounty":"","pcpid":"","pcpname":"ASCENSION VIA CHRISTI PHYSICIAN GROUP","plan":"BCBSKS","program":"Medicare","lob":"012","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"717 E. Campus Street","madd2":"","madd3":"","mcity":"WICHITA","mstate":"KS","mzip":"67216","pcpfaxno":"","pcpnpi":"1609499219","currentgendcomment":"","pphycomment":"","uniqueid":"M3AK44008142","medicareid":"6TK5M70UQ89","medicaidid":"6TK5M70UQ89","pcpFlag":"","dob":"1949-10-24"},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":{"indx":["","1"],"comment":["",""],"sub":{"indx":[["Spanish"]],"comment":[[]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":{"0":{"a":{"diag":["Z780","M85851","M85852","I10","E119","E611","E559","M8580","E785","H579","M1990","I129","N1831","E7849","D6489","H35342","H353131","E7800","D7589","R748","R92333","R7989","E1121","D631","Z961","N6310","N6320","R54","M79602","K5900"],"date":["2025-07-23","2025-07-23","2025-07-23","2026-05-28","2026-05-28","2026-05-28","2026-05-28","2026-05-28","2026-05-28","2025-08-14","2025-08-14","2025-10-21","2025-10-21","2025-10-21","2025-10-21","2025-11-12","2026-06-10","2026-01-08","2025-12-08","2025-01-29","2026-04-23","2025-05-01","2025-06-12","2025-06-12","2026-02-11","2026-04-23","2026-04-23","2026-05-20","2026-05-28","2026-05-28"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","",""]}},"1":{"a":[]},"3":{"a":{"indx":["","1"],"comment":["",""],"sub":{"indx":[["Spanish"]],"comment":[[]],"sub":[]}}}}},{"t":"COVID Screening","q":[{"a":[]},{"a":[]},{"a":[]}]},{"t":"Self-Assessment and Social History (SDOH)","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":[]}]},{"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":[]}]},{"t":"Allergies \/ Medications","q":[{"a":[]},{"a":{"comment":"","sub":[["","","FLUZONE HIGH-DOSE 2025-2026","","","Select","Select",""],["","","PREDNISOLONE ACETATE","1%","","Select","Select",""],["","","DILTIAZEM HYDROCHLORIDE ER","120 MG","","Select","Select",""],["","","CHLORTHALIDONE","25 MG","","Select","Select",""],["","","KETOROLAC TROMETHAMINE","0.50%","","Select","Select",""],["","","LISINOPRIL","40 MG","","Select","Select",""],["","","ATORVASTATIN CALCIUM","40 MG","","Select","Select",""],["","","MOXIFLOXACIN HYDROCHLORIDE","0.50%","","Select","Select",""],["","","DORZOLAMIDE HYDROCHLORIDE","2%","","Select","Select",""],["","","JARDIANCE","10 MG","","Select","Select",""],["","","Fluzone Hd Inj 2025-26","","","Select","Select",""],["","","Ketorolac Sol 0.5% Op","","","Select","Select",""],["","","Diltiazem Cap","120 MG","","Select","Select",""],["","","Prednisolone Sus 1% Op","","","Select","Select",""],["","","Lisinopril Tab","40 MG","","Select","Select",""],["","","Chlorthalid Tab","25 MG","","Select","Select",""],["","","Moxifloxacin Sol Hcl 0.5%","","","Select","Select",""],["","","Atorvastatin Tab","40 MG","","Select","Select",""]]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Assessment of 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":[]}]},{"t":"Pain","q":[{"a":[]}]},{"t":"Vital Signs","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Exam Review","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Screenings Needed","q":[{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":[]}]},{"t":"Mini-Cog","q":[{"a":[]},{"a":[]},{"a":[]}]},{"t":"Home Safety & Personal Goals","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"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":"","a13":""}]}]}