{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CLARICE E DICK","gend":1,"currentgend":"","add":"4956 Nemaha Road","city":"Perry","state":"KS","zip":"66073","dob":"1936-07-13","age":"","mstatus":"","insh":"K44009782","cliId":"","pno":"7858172948","cno":"","email":"mdicklang@gmail.com","ename":"","eno":"","pphy":"CATHRYN PALENSKE","ppno":"9139334020","pcpadd":"408 DELAWARE ST","pcpcity":"WINCHESTER","pcpstate":"KS","pcpzip":"66097-4003","pcpcounty":"","pcpid":"","pcpname":"JEFFERSON MEDICAL CLINIC","plan":"BCBSKS","program":"Medicare","lob":"001","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"4956 Nemaha Road","madd2":"","madd3":"","mcity":"Perry","mstate":"KS","mzip":"66073","pcpfaxno":"","pcpnpi":"1083345920","currentgendcomment":"","pphycomment":"","uniqueid":"M3AK44009782","medicareid":"3V06CG7GE62","medicaidid":"3V06CG7GE62","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E785","I480","K760","R011","R600","I253","I739","B351","L603","I10","Z7901","Z79899","Z8781","M25561","M25562","G8929","J069","R062","H04123","H01021","Z961","H26493","Z7689","I083","I119","R9431","R2689","M6281","R54","I728","Z789","Z634","I350"],"date":["2026-05-26","2026-05-26","2026-05-26","2026-04-22","2026-05-26","2025-08-21","2025-11-19","2026-05-04","2026-05-04","2026-05-26","2026-06-08","2026-06-08","2026-04-22","2025-10-14","2025-10-14","2025-10-14","2025-11-18","2025-11-18","2025-02-25","2025-02-25","2025-02-25","2025-02-25","2026-06-08","2026-06-08","2025-06-10","2025-06-10","2025-08-29","2025-08-29","2025-08-29","2025-08-21","2026-04-22","2026-04-22","2026-05-26"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",""]}},{"a":[]}]},{"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":[["","","CHLORHEXIDINE GLUCONATE","0.12%","","Select","Select",""],["","","AMOXICILLIN","500 MG","","Select","Select",""],["","","LOSARTAN POTASSIUM","50 MG","","Select","Select",""],["","","HYDROCODONE BITARTRATE\/ACETAMINOPHEN","325 MG","","Select","Select",""],["","","ELIQUIS","5 MG","","Select","Select",""],["","","CARTIA XT","","","Select","Select",""],["","","ALBUTEROL SULFATE","0.08%","","Select","Select",""],["","","AZITHROMYCIN","250 MG","","Select","Select",""],["","","AMOXICILLIN\/CLAVULANATE POTASSIUM","","","Select","Select",""],["","","AREXVY","120 MCG","","Select","Select",""],["","","DILTIAZEM HYDROCHLORIDE ER","240 MG","","Select","Select",""],["","","NYSTATIN","","","Select","Select",""],["","","Arexvy Inj","120 MCG","","Select","Select",""],["","","Albuterol Neb 0.083%","","","Select","Select",""],["","","Losartan Pot Tab","50 MG","","Select","Select",""],["","","Amoxicillin Cap","500 MG","","Select","Select",""],["","","Nystatin Pow 100000","","","Select","Select",""],["","","Cartia Xt Cap 240\/24Hr","","","Select","Select",""],["","","Chlorhex Glu Sol 0.12%","","","Select","Select",""],["","","Diltiazem Cap","240 MG","","Select","Select",""],["","","Hydroco\/Apap Tab 5-325Mg","","","Select","Select",""],["","","Azithromycin Tab","250 MG","","Select","Select",""],["","","Amox\/K Clav Tab 875-125","","","Select","Select",""],["","","Eliquis Tab","5 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":""}]}]}