{ "version": "0.4", "data": [ { "t": "Demographics", "q": [ { "name": "WALTER E PEARL", "gend": 0, "currentgend": "", "add": "233 BLAKE LANE", "city": "OAKLAND", "state": "ME", "zip": 4963, "dob": "1950-06-02", "age": "", "mstatus": "", "insh": "10000042235", "cliId": "", "pno": 2074653799, "cno": "", "email": "roemax@twc.com", "ename": "", "eno": "", "pphy": "STEVENS, ROBERT B", "ppno": 2074652181, "pcpadd": "Oakland Family Medicine,9 Pleasant St", "pcpcity": "Oakland", "pcpstate": "ME", "pcpzip": 4963, "pcpcounty": "", "pcpid": "", "pcpname": "OAKLAND FAMILY MEDICINE", "plan": "Martin's Point", "program": "MEDICARE", "lob": "GA - 2025", "region": "", "aligned": "", "ano": "", "add2": "", "add3": "", "madd1": "250 MANCHESTER RD", "madd2": "", "madd3": "", "mcity": "Steep Falls", "mstate": "ME", "mzip": 4085, "pcpfaxno": 2074654629, "pcpnpi": 1407176175, "currentgendcomment": "", "pphycomment": "", "uniqueid": "", "medicareid": "1HT9HD8EE46", "medicaidid": "", "pcpFlag": "" }, { "a": { "indx": [ "1", "", "", "", "", "", "", "" ], "comment": [ "", "", "", "", "", "", "", "" ], "sub": [] } }, { "a": [] }, { "a": [] }, { "a": [] }, { "a": [] } ] }, { "t": "Previously Documented Conditions", "q": [ { "a": { "diag": [ "E1136", "C9110", "L280", "E1122", "I129", "N1830", "D631", "H25813", "S61451A", "W5501XA", "R809", "H25811", "N1330", "L432", "S91201A", "X58XXXA", "N184", "Z0000", "N1831", "Z961", "H52223", "R051", "R319", "N189", "Z48810", "R310", "N3091", "E119", "E1165", "Z9842", "E039", "N3944", "D472", "R634", "Z8619", "M7989", "M79642", "Z20822", "L309", "R339", "R32", "Z794", "R5383", "Z87891", "J22", "E7800", "T383X6A", "Z91148", "S6392XA", "W1830XA", "Z7984", "I10", "R531", "N3289", "N3090", "K8020", "N400", "S61012A", "W278XXA", "Y9389", "Z0101", "R768", "R6889" ], "date": [ "2022-08-11", "2024-12-30", "2025-01-07", "2025-02-03", "2024-11-08", "2022-11-08", "2022-11-08", "2022-07-28", "2024-01-30", "2024-01-30", "2023-10-09", "2022-08-11", "2025-01-26", "2025-01-07", "2022-10-24", "2022-10-24", "2025-01-03", "2023-07-07", "2023-11-03", "2023-12-14", "2023-12-14", "2022-09-06", "2024-08-09", "2024-12-26", "2022-08-05", "2025-01-26", "2025-01-26", "2025-01-16", "2025-01-09", "2022-08-11", "2024-12-06", "2025-01-09", "2024-12-30", "2024-12-30", "2024-12-30", "2023-05-16", "2023-05-16", "2022-09-06", "2024-05-06", "2025-01-16", "2025-01-16", "2025-01-16", "2022-06-10", "2025-01-07", "2022-09-14", "2023-11-03", "2024-10-18", "2024-10-18", "2023-05-16", "2023-05-16", "2023-05-16", "2023-05-10", "2023-05-10", "2025-01-15", "2025-01-26", "2025-01-26", "2025-01-26", "2024-09-11", "2024-09-11", "2024-09-11", "2022-04-25", "2022-02-04", "2021-12-27" ], "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": [ [ "", "", "NANO 2ND GEN PEN NEEDLE", "", "", "Select", "Select", "" ], [ "", "", "PAROXETINE HCL", "", "", "Select", "Select", "" ], [ "", "", "LEVOTHYROXINE SODIUM", "", "", "Select", "Select", "" ], [ "", "", "LANTUS SOLOSTAR", "", "", "Select", "Select", "" ], [ "", "", "RYBELSUS", "", "", "Select", "Select", "" ], [ "", "", "ONETOUCH VERIO TEST STRIP", "", "", "Select", "Select", "" ], [ "", "", "ONETOUCH DELICA PLUS LANC DEV", "", "", "Select", "Select", "" ], [ "", "", "PANTOPRAZOLE SODIUM", "", "", "Select", "Select", "" ], [ "", "", "AMITRIPTYLINE HCL", "", "", "Select", "Select", "" ], [ "", "", "METFORMIN HCL", "", "", "Select", "Select", "" ], [ "", "", "GLIPIZIDE", "", "", "Select", "Select", "" ], [ "", "", "IBU", "", "", "Select", "Select", "" ], [ "", "", "BENAZEPRIL HCL", "", "", "Select", "Select", "" ], [ "", "", "ONETOUCH DELICA PLUS LANCET", "", "", "Select", "Select", "" ], [ "", "", "TOUJEO SOLOSTAR", "", "", "Select", "Select", "" ], [ "", "", "PREDNISONE", "", "", "Select", "Select", "" ], [ "", "", "GLIPIZIDE ER", "", "", "Select", "Select", "" ], [ "", "", "CHLORTHALIDONE", "", "", "Select", "Select", "" ], [ "", "", "ONETOUCH VERIO FLEX METER", "", "", "Select", "Select", "" ], [ "", "", "CIPROFLOXACIN HCL", "", "", "Select", "Select", "" ], [ "", "", "AMOXICILLIN-CLAVULANATE POTASS", "", "", "Select", "Select", "" ], [ "", "", "BETAMETHASONE DIPROPIONATE", "", "", "Select", "Select", "" ], [ "", "", "EUTHYROX", "", "", "Select", "Select", "" ], [ "", "", "MODERNA COVID BIVAL(6MO UP)EUA", "", "", "Select", "Select", "" ], [ "", "", "AZITHROMYCIN", "", "", "Select", "Select", "" ], [ "", "", "ONETOUCH VERIO REFLECT METER", "", "", "Select", "Select", "" ], [ "", "", "LEVO-T", "", "", "Select", "Select", "" ], [ "", "", "MODERNA COVID (12Y UP)VAC(EUA)", "", "", "Select", "Select", "" ], [ "", "", "HYDROCODONE-ACETAMINOPHEN", "", "", "Select", "Select", "" ], [ "", "", "CHLORHEXIDINE GLUCONATE", "", "", "Select", "Select", "" ], [ "", "", "AMOXICILLIN", "", "", "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": [ "", "1" ], "comment": [ "", "" ], "sub": [] } }, { "a": { "indx": [ "1", "" ], "comment": [ "", "" ], "sub": [] } }, { "a": { "indx": [ "1", "" ], "comment": [ "", "" ], "sub": [] } }, { "a": { "indx": [ "", "1" ], "comment": [ "", "" ], "sub": [] } }, { "a": { "indx": [ "1", "" ], "comment": [ "", "" ], "sub": { "indx": [ [ "", "", "", "" ], [], [ "" ], [ "" ], [], [ "" ], [ "" ] ], "comment": [ [ "", "", "", "" ], [ "" ], [ "" ], [ "" ], [ "" ] ], "sub": [] } } }, { "a": { "indx": [ "", "1" ], "comment": [ "", "" ], "sub": { "indx": [ [ "", "", "", "" ], [], [ "" ], [ "" ], [ "" ], [ "" ], [ "" ], [ "" ] ], "comment": [ [ "", "", "", "" ], [ "" ], [ "" ], [ "" ], [ "" ] ], "sub": [] } } }, { "a": { "indx": [ "", "1" ], "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": "" } ] } ] }