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          "text": "Not at all"
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          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
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        "code": {
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          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
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        "valueCodeableConcept": {
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          "text": "No"
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          "text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
        },
        "valueCodeableConcept": {
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          "text": "Food"
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            "code": "63586-2",
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          "text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
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          "text": "Primary insurance"
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          "text": "Medicare"
        }
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        "code": {
          "coding": [ {
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          "text": "Employment status - current"
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        }
      }, {
        "code": {
          "coding": [ {
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            "code": "82589-3",
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          "text": "Highest level of education"
        },
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          "coding": [ {
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            "code": "LA30191-3",
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          "text": "Less than high school degree"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "56799-0",
            "display": "Address"
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          "text": "Address"
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        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93033-9",
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          "text": "Are you worried about losing your housing?"
        },
        "valueCodeableConcept": {
          "coding": [ {
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          "text": "Yes"
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      }, {
        "code": {
          "coding": [ {
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            "code": "71802-3",
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          "text": "Housing status"
        },
        "valueCodeableConcept": {
          "coding": [ {
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            "code": "LA30189-7",
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          "text": "I have housing"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
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            "display": "How many people are living or staying at this address?"
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          "text": "How many people are living or staying at this address?"
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          "text": "Preferred language"
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          "text": "English"
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      }, {
        "code": {
          "coding": [ {
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          "text": "Have you been discharged from the armed forces of the United States?"
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          "text": "No"
        }
      }, {
        "code": {
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          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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            "display": "Race"
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          "text": "Race"
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          "coding": [ {
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            "code": "LA4457-3",
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          "text": "White"
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        "code": {
          "coding": [ {
            "system": "http://loinc.org",
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            "display": "Do you consider yourself Hispanic/Latino?"
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          "text": "Do you consider yourself Hispanic/Latino?"
        },
        "valueCodeableConcept": {
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          "text": "No"
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          "display": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
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        "text": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
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        "text": "Total score [DAST-10]"
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        "text": "Assessment of health and social care needs (procedure)"
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        "text": "Screening for drug abuse (procedure)"
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        "coding": [ {
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        "text": "Community"
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        "coding": [ {
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          "code": "2947-0",
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        } ],
        "text": "Sodium [Moles/volume] in Blood"
      },
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        "code": "mmol/L"
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    },
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      "url": "Observation"
    }
  }, {
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      } ],
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        "coding": [ {
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          "code": "6298-4",
          "display": "Potassium [Moles/volume] in Blood"
        } ],
        "text": "Potassium [Moles/volume] in Blood"
      },
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      },
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    }
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          "display": "Laboratory"
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      } ],
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        "coding": [ {
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          "code": "2069-3",
          "display": "Chloride [Moles/volume] in Blood"
        } ],
        "text": "Chloride [Moles/volume] in Blood"
      },
      "subject": {
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      },
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        "code": "mmol/L"
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    },
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      "url": "Observation"
    }
  }, {
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      },
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        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "20565-8",
          "display": "Carbon dioxide, total [Moles/volume] in Blood"
        } ],
        "text": "Carbon dioxide, total [Moles/volume] in Blood"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
      },
      "encounter": {
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        "code": "mmol/L"
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    },
    "request": {
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      "url": "Observation"
    }
  }, {
    "fullUrl": "urn:uuid:b3e16e38-00c1-d694-7a01-d42767d6601f",
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      "resourceType": "Observation",
      "id": "b3e16e38-00c1-d694-7a01-d42767d6601f",
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab" ]
      },
      "status": "final",
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        "coding": [ {
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        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "2093-3",
          "display": "Cholesterol [Mass/volume] in Serum or Plasma"
        } ],
        "text": "Cholesterol [Mass/volume] in Serum or Plasma"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
      },
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        "value": 252.85,
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        "system": "http://unitsofmeasure.org",
        "code": "mg/dL"
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    },
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      "url": "Observation"
    }
  }, {
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab" ]
      },
      "status": "final",
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "2571-8",
          "display": "Triglycerides"
        } ],
        "text": "Triglycerides"
      },
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      },
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        "system": "http://unitsofmeasure.org",
        "code": "mg/dL"
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    },
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      "url": "Observation"
    }
  }, {
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab" ]
      },
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "18262-6",
          "display": "Low Density Lipoprotein Cholesterol"
        } ],
        "text": "Low Density Lipoprotein Cholesterol"
      },
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      "url": "Observation"
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  }, {
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      },
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "display": "Cholesterol in HDL [Mass/volume] in Serum or Plasma"
        } ],
        "text": "Cholesterol in HDL [Mass/volume] in Serum or Plasma"
      },
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    }
  }, {
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      "id": "3e738171-04ed-fb57-8eaa-2c3b74e1fb70",
      "meta": {
        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-social-history" ]
      },
      "status": "final",
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          "code": "social-history",
          "display": "Social history"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "72166-2",
          "display": "Tobacco smoking status"
        } ],
        "text": "Tobacco smoking status"
      },
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        "text": "Ex-smoker (finding)"
      }
    },
    "request": {
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  }, {
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
      },
      "status": "final",
      "category": [ {
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          "code": "survey",
          "display": "Survey"
        } ]
      } ],
      "code": {
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          "code": "93025-5",
          "display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
      },
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          } ],
          "text": "Within the last year, have you been afraid of your partner or ex-partner?"
        },
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          "text": "No"
        }
      }, {
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          "coding": [ {
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          "text": "Do you feel physically and emotionally safe where you currently live?"
        },
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          "text": "Yes"
        }
      }, {
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          "text": "Are you a refugee?"
        },
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          "text": "No"
        }
      }, {
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            "code": "93028-9",
            "display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
          } ],
          "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
        },
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          "text": "Yes"
        }
      }, {
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          "text": "Stress level"
        },
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          "text": "Not at all"
        }
      }, {
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            "display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
          } ],
          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
        },
        "valueCodeableConcept": {
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        }
      }, {
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          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
        },
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          "text": "No"
        }
      }, {
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          } ],
          "text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
        },
        "valueCodeableConcept": {
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          "text": "I choose not to answer this question"
        }
      }, {
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            "display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
          } ],
          "text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
        },
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            "display": "Primary insurance"
          } ],
          "text": "Primary insurance"
        },
        "valueCodeableConcept": {
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            "code": "LA15652-3",
            "display": "Medicare"
          } ],
          "text": "Medicare"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "67875-5",
            "display": "Employment status - current"
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          "text": "Employment status - current"
        },
        "valueCodeableConcept": {
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            "code": "LA30136-8",
            "display": "Full-time work"
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          "text": "Full-time work"
        }
      }, {
        "code": {
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            "code": "82589-3",
            "display": "Highest level of education"
          } ],
          "text": "Highest level of education"
        },
        "valueCodeableConcept": {
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            "code": "LA30191-3",
            "display": "Less than high school degree"
          } ],
          "text": "Less than high school degree"
        }
      }, {
        "code": {
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            "code": "56799-0",
            "display": "Address"
          } ],
          "text": "Address"
        },
        "valueString": "318 Goldner Fork Unit 86"
      }, {
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          "coding": [ {
            "system": "http://loinc.org",
            "code": "93033-9",
            "display": "Are you worried about losing your housing?"
          } ],
          "text": "Are you worried about losing your housing?"
        },
        "valueCodeableConcept": {
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            "system": "http://loinc.org",
            "code": "LA33-6",
            "display": "Yes"
          } ],
          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "71802-3",
            "display": "Housing status"
          } ],
          "text": "Housing status"
        },
        "valueCodeableConcept": {
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            "code": "LA30189-7",
            "display": "I have housing"
          } ],
          "text": "I have housing"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "63512-8",
            "display": "How many people are living or staying at this address?"
          } ],
          "text": "How many people are living or staying at this address?"
        },
        "valueQuantity": {
          "value": 8,
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          "code": "{#}"
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            "code": "54899-0",
            "display": "Preferred language"
          } ],
          "text": "Preferred language"
        },
        "valueCodeableConcept": {
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            "code": "LA43-5",
            "display": "English"
          } ],
          "text": "English"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93034-7",
            "display": "Have you been discharged from the armed forces of the United States?"
          } ],
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      },
      "status": "final",
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        } ],
        "text": "Sodium [Moles/volume] in Blood"
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        "text": "Potassium [Moles/volume] in Blood"
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        } ],
        "text": "Chloride [Moles/volume] in Blood"
      },
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        "coding": [ {
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        "text": "Carbon dioxide, total [Moles/volume] in Blood"
      },
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      },
      "status": "final",
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      } ],
      "code": {
        "coding": [ {
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          "code": "72166-2",
          "display": "Tobacco smoking status"
        } ],
        "text": "Tobacco smoking status"
      },
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      }
    },
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      } ],
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        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
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          "text": "No"
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      }, {
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          "text": "Are you a refugee?"
        },
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          "text": "Yes"
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      }, {
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          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
        },
        "valueCodeableConcept": {
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          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
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          "text": "Primary insurance"
        },
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          "text": "Medicare"
        }
      }, {
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          "text": "Employment status - current"
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          "text": "Unemployed"
        }
      }, {
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          "text": "Highest level of education"
        },
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          "text": "Less than high school degree"
        }
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          "text": "Address"
        },
        "valueString": "318 Goldner Fork Unit 86"
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          "text": "Are you worried about losing your housing?"
        },
        "valueCodeableConcept": {
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          "text": "Yes"
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          "text": "I have housing"
        }
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          "text": "How many people are living or staying at this address?"
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          "text": "English"
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          "text": "Have you been discharged from the armed forces of the United States?"
        },
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          } ],
          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
      }, {
        "code": {
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          "text": "Race"
        },
        "valueCodeableConcept": {
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          "text": "White"
        }
      }, {
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          "coding": [ {
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          } ],
          "text": "Do you consider yourself Hispanic/Latino?"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
      } ]
    },
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  }, {
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      },
      "status": "final",
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        } ]
      } ],
      "code": {
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          "system": "http://loinc.org",
          "code": "70274-6",
          "display": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
        } ],
        "text": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
      },
      "subject": {
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        "unit": "{score}",
        "system": "http://unitsofmeasure.org",
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    },
    "request": {
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  }, {
    "fullUrl": "urn:uuid:9ff704d8-b6ed-8925-83d1-3ecad3754010",
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      "id": "9ff704d8-b6ed-8925-83d1-3ecad3754010",
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
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        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "76504-0",
          "display": "Total score [HARK]"
        } ],
        "text": "Total score [HARK]"
      },
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        "code": "{score}"
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    "request": {
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      },
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      } ],
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        "coding": [ {
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        } ],
        "text": "Urea nitrogen [Mass/volume] in Blood"
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  }, {
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        } ]
      } ],
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        "coding": [ {
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          "display": "Creatinine [Mass/volume] in Blood"
        } ],
        "text": "Creatinine [Mass/volume] in Blood"
      },
      "subject": {
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      },
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    },
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  }, {
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      } ],
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        "coding": [ {
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          "display": "Calcium [Mass/volume] in Blood"
        } ],
        "text": "Calcium [Mass/volume] in Blood"
      },
      "subject": {
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    },
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  }, {
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      },
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      } ],
      "code": {
        "coding": [ {
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          "code": "2947-0",
          "display": "Sodium [Moles/volume] in Blood"
        } ],
        "text": "Sodium [Moles/volume] in Blood"
      },
      "subject": {
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        "code": "mmol/L"
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    },
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      "url": "Observation"
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  }, {
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab" ]
      },
      "status": "final",
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          "display": "Laboratory"
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      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "6298-4",
          "display": "Potassium [Moles/volume] in Blood"
        } ],
        "text": "Potassium [Moles/volume] in Blood"
      },
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      },
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        "code": "mmol/L"
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    },
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  }, {
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        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "2069-3",
          "display": "Chloride [Moles/volume] in Blood"
        } ],
        "text": "Chloride [Moles/volume] in Blood"
      },
      "subject": {
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      },
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        "code": "mmol/L"
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  }, {
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab" ]
      },
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "20565-8",
          "display": "Carbon dioxide, total [Moles/volume] in Blood"
        } ],
        "text": "Carbon dioxide, total [Moles/volume] in Blood"
      },
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      "url": "Observation"
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  }, {
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-social-history" ]
      },
      "status": "final",
      "category": [ {
        "coding": [ {
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          "code": "social-history",
          "display": "Social history"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "72166-2",
          "display": "Tobacco smoking status"
        } ],
        "text": "Tobacco smoking status"
      },
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        "text": "Ex-smoker (finding)"
      }
    },
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  }, {
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
      },
      "status": "final",
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      } ],
      "code": {
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          "display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
      },
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          } ],
          "text": "Within the last year, have you been afraid of your partner or ex-partner?"
        },
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          "text": "No"
        }
      }, {
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          "text": "Do you feel physically and emotionally safe where you currently live?"
        },
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      }, {
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          "text": "Are you a refugee?"
        },
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          "text": "No"
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      }, {
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            "display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
          } ],
          "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
        },
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          "text": "Yes"
        }
      }, {
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          "text": "Stress level"
        },
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          "text": "A little bit"
        }
      }, {
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          } ],
          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
        },
        "valueCodeableConcept": {
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      }, {
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          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
        },
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          "text": "No"
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      }, {
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          "text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
        },
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      }, {
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          } ],
          "text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
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            "display": "Primary insurance"
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          "text": "Primary insurance"
        },
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          "text": "Medicare"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "67875-5",
            "display": "Employment status - current"
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          "text": "Employment status - current"
        },
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            "code": "LA17956-6",
            "display": "Unemployed"
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          "text": "Unemployed"
        }
      }, {
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          "coding": [ {
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            "display": "Highest level of education"
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          "text": "Highest level of education"
        },
        "valueCodeableConcept": {
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            "display": "Less than high school degree"
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          "text": "Less than high school degree"
        }
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            "code": "56799-0",
            "display": "Address"
          } ],
          "text": "Address"
        },
        "valueString": "318 Goldner Fork Unit 86"
      }, {
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            "code": "93033-9",
            "display": "Are you worried about losing your housing?"
          } ],
          "text": "Are you worried about losing your housing?"
        },
        "valueCodeableConcept": {
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            "code": "LA33-6",
            "display": "Yes"
          } ],
          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "71802-3",
            "display": "Housing status"
          } ],
          "text": "Housing status"
        },
        "valueCodeableConcept": {
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            "code": "LA30189-7",
            "display": "I have housing"
          } ],
          "text": "I have housing"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "63512-8",
            "display": "How many people are living or staying at this address?"
          } ],
          "text": "How many people are living or staying at this address?"
        },
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          "code": "{#}"
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            "display": "Preferred language"
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          "text": "Preferred language"
        },
        "valueCodeableConcept": {
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          } ],
          "text": "English"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93034-7",
            "display": "Have you been discharged from the armed forces of the United States?"
          } ],
          "text": "Have you been discharged from the armed forces of the United States?"
        },
        "valueCodeableConcept": {
          "coding": [ {
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            "code": "LA32-8",
            "display": "No"
          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93035-4",
            "display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
          } ],
          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
        },
        "valueCodeableConcept": {
          "coding": [ {
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            "display": "No"
          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "32624-9",
            "display": "Race"
          } ],
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          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
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          "text": "Do you consider yourself Hispanic/Latino?"
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        "text": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
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        "text": "Total score [DAST-10]"
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        "text": "Assessment of health and social care needs (procedure)"
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        "text": "Assessment of anxiety (procedure)"
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        } ],
        "text": "Creatinine [Mass/volume] in Blood"
      },
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        "text": "Calcium [Mass/volume] in Blood"
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        "text": "Sodium [Moles/volume] in Blood"
      },
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        "text": "Potassium [Moles/volume] in Blood"
      },
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        "text": "Chloride [Moles/volume] in Blood"
      },
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        "text": "Carbon dioxide, total [Moles/volume] in Blood"
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      },
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      } ],
      "code": {
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        "text": "Tobacco smoking status"
      },
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        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
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          "text": "Yes"
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          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
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          "text": "Medicare"
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          "text": "Employment status - current"
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          "text": "Highest level of education"
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          "text": "Less than high school degree"
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          "text": "Address"
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        "valueString": "318 Goldner Fork Unit 86"
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          "text": "Are you worried about losing your housing?"
        },
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          "text": "Yes"
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          "text": "Housing status"
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        }
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          "text": "How many people are living or staying at this address?"
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          "text": "Have you been discharged from the armed forces of the United States?"
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        "valueCodeableConcept": {
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          "text": "No"
        }
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            "display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
          } ],
          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
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          "text": "Race"
        },
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      } ],
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        "text": "Tobacco smoking status"
      },
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      } ],
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        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
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          "text": "Medicare"
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      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "93025-5",
          "display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
      },
      "encounter": {
        "reference": "urn:uuid:8fb9fef2-1fd3-0f51-daa9-aaea4328415d"
      },
      "effectiveDateTime": "2015-04-05T03:57:55+02:00",
      "issued": "2015-04-05T03:57:55.194+02:00",
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        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "76501-6",
            "display": "Within the last year, have you been afraid of your partner or ex-partner?"
          } ],
          "text": "Within the last year, have you been afraid of your partner or ex-partner?"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA32-8",
            "display": "No"
          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93026-3",
            "display": "Do you feel physically and emotionally safe where you currently live?"
          } ],
          "text": "Do you feel physically and emotionally safe where you currently live?"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA33-6",
            "display": "Yes"
          } ],
          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93027-1",
            "display": "Are you a refugee?"
          } ],
          "text": "Are you a refugee?"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA32-8",
            "display": "No"
          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93028-9",
            "display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
          } ],
          "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA33-6",
            "display": "Yes"
          } ],
          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93038-8",
            "display": "Stress level"
          } ],
          "text": "Stress level"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA13863-8",
            "display": "A little bit"
          } ],
          "text": "A little bit"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
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            "display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
          } ],
          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA30131-9",
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          "text": "3 to 5 times a week"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93030-5",
            "display": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
          } ],
          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA32-8",
            "display": "No"
          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
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            "display": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
          } ],
          "text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA30122-8",
            "display": "I choose not to answer this question"
          } ],
          "text": "I choose not to answer this question"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "63586-2",
            "display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
          } ],
          "text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
        },
        "valueQuantity": {
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          "system": "http://unitsofmeasure.org",
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        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "76437-3",
            "display": "Primary insurance"
          } ],
          "text": "Primary insurance"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA15652-3",
            "display": "Medicare"
          } ],
          "text": "Medicare"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "67875-5",
            "display": "Employment status - current"
          } ],
          "text": "Employment status - current"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA17956-6",
            "display": "Unemployed"
          } ],
          "text": "Unemployed"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "82589-3",
            "display": "Highest level of education"
          } ],
          "text": "Highest level of education"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA30191-3",
            "display": "Less than high school degree"
          } ],
          "text": "Less than high school degree"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "56799-0",
            "display": "Address"
          } ],
          "text": "Address"
        },
        "valueString": "318 Goldner Fork Unit 86"
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93033-9",
            "display": "Are you worried about losing your housing?"
          } ],
          "text": "Are you worried about losing your housing?"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA33-6",
            "display": "Yes"
          } ],
          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "71802-3",
            "display": "Housing status"
          } ],
          "text": "Housing status"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA30189-7",
            "display": "I have housing"
          } ],
          "text": "I have housing"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "63512-8",
            "display": "How many people are living or staying at this address?"
          } ],
          "text": "How many people are living or staying at this address?"
        },
        "valueQuantity": {
          "value": 8,
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          "system": "http://unitsofmeasure.org",
          "code": "{#}"
        }
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          "coding": [ {
            "system": "http://loinc.org",
            "code": "54899-0",
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          } ],
          "text": "Preferred language"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA43-5",
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          } ],
          "text": "English"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93034-7",
            "display": "Have you been discharged from the armed forces of the United States?"
          } ],
          "text": "Have you been discharged from the armed forces of the United States?"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA32-8",
            "display": "No"
          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93035-4",
            "display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
          } ],
          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
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            "display": "No"
          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "32624-9",
            "display": "Race"
          } ],
          "text": "Race"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA4457-3",
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          } ],
          "text": "White"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "56051-6",
            "display": "Do you consider yourself Hispanic/Latino?"
          } ],
          "text": "Do you consider yourself Hispanic/Latino?"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA32-8",
            "display": "No"
          } ],
          "text": "No"
        }
      } ]
    },
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      "method": "POST",
      "url": "Observation"
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  }, {
    "fullUrl": "urn:uuid:232b0b27-d072-bea3-3c1e-c52d86d309b5",
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      "resourceType": "Observation",
      "id": "232b0b27-d072-bea3-3c1e-c52d86d309b5",
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
      },
      "status": "final",
      "category": [ {
        "coding": [ {
          "system": "http://terminology.hl7.org/CodeSystem/observation-category",
          "code": "survey",
          "display": "Survey"
        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "70274-6",
          "display": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
        } ],
        "text": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
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        "reference": "urn:uuid:8fb9fef2-1fd3-0f51-daa9-aaea4328415d"
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        "system": "http://unitsofmeasure.org",
        "code": "{score}"
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    },
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  }, {
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      "id": "d05ed150-6903-2ff9-f228-6a953e0d8590",
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
      },
      "status": "final",
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        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "59460-6",
          "display": "Fall risk total [Morse Fall Scale]"
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        "text": "Fall risk total [Morse Fall Scale]"
      },
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      },
      "encounter": {
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        "unit": "{#}",
        "system": "http://unitsofmeasure.org",
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  }, {
    "fullUrl": "urn:uuid:ae45d984-b11e-9e26-fb8d-574b9ba1f090",
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
      },
      "status": "final",
      "category": [ {
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          "display": "Survey"
        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "59461-4",
          "display": "Fall risk level [Morse Fall Scale]"
        } ],
        "text": "Fall risk level [Morse Fall Scale]"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
      },
      "encounter": {
        "reference": "urn:uuid:8fb9fef2-1fd3-0f51-daa9-aaea4328415d"
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      "effectiveDateTime": "2015-04-05T04:40:18+02:00",
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        "coding": [ {
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          "display": "High Risk (MFS Score 50+)"
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        "text": "High Risk (MFS Score 50+)"
      }
    },
    "request": {
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      "url": "Observation"
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  }, {
    "fullUrl": "urn:uuid:c4f41f6c-19bc-51eb-d6dc-1d99ec088935",
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      "id": "c4f41f6c-19bc-51eb-d6dc-1d99ec088935",
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      },
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          "display": "Survey"
        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "55758-7",
          "display": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
        } ],
        "text": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
      },
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      "effectiveDateTime": "2015-04-05T05:23:13+02:00",
      "issued": "2015-04-05T05:23:13.194+02:00",
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        "unit": "{score}",
        "system": "http://unitsofmeasure.org",
        "code": "{score}"
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    },
    "request": {
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      "url": "Observation"
    }
  }, {
    "fullUrl": "urn:uuid:436c2cb6-053b-aa3f-80b0-d94e9ca3aa54",
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
      },
      "status": "final",
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        "coding": [ {
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          "display": "Survey"
        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "82667-7",
          "display": "Total score [DAST-10]"
        } ],
        "text": "Total score [DAST-10]"
      },
      "subject": {
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        "text": "Medication Reconciliation (procedure)"
      },
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      "encounter": {
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure" ]
      },
      "status": "completed",
      "code": {
        "coding": [ {
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          "code": "710824005",
          "display": "Assessment of health and social care needs (procedure)"
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        "text": "Assessment of health and social care needs (procedure)"
      },
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      },
      "status": "completed",
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        "text": "Assessment of anxiety (procedure)"
      },
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        "coding": [ {
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        "text": "Ex-smoker (finding)"
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    },
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        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
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          "text": "Within the last year, have you been afraid of your partner or ex-partner?"
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      }, {
        "code": {
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        },
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          "text": "No"
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          "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
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          "text": "Yes"
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        "code": {
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          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
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        "valueCodeableConcept": {
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          "text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
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          "text": "Medicare"
        }
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          "text": "Employment status - current"
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        "code": {
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          "text": "Highest level of education"
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          "text": "Less than high school degree"
        }
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        "code": {
          "coding": [ {
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            "code": "56799-0",
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          "text": "Address"
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          } ],
          "text": "Are you worried about losing your housing?"
        },
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          "text": "Have you been discharged from the armed forces of the United States?"
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          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
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          "text": "No"
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        "code": {
          "coding": [ {
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          "text": "Do you consider yourself Hispanic/Latino?"
        },
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        "text": "Total score [AUDIT-C]"
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          "text": "insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Humulin]"
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        "code": "mmol/L"
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    },
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      "url": "Observation"
    }
  }, {
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      },
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "6298-4",
          "display": "Potassium [Moles/volume] in Blood"
        } ],
        "text": "Potassium [Moles/volume] in Blood"
      },
      "subject": {
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      },
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    },
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      "url": "Observation"
    }
  }, {
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "2069-3",
          "display": "Chloride [Moles/volume] in Blood"
        } ],
        "text": "Chloride [Moles/volume] in Blood"
      },
      "subject": {
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      },
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        "code": "mmol/L"
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    },
    "request": {
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      "url": "Observation"
    }
  }, {
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      },
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "20565-8",
          "display": "Carbon dioxide, total [Moles/volume] in Blood"
        } ],
        "text": "Carbon dioxide, total [Moles/volume] in Blood"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
      },
      "encounter": {
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        "system": "http://unitsofmeasure.org",
        "code": "mmol/L"
      }
    },
    "request": {
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      "url": "Observation"
    }
  }, {
    "fullUrl": "urn:uuid:19a474a9-dd4a-89f0-6e2b-91f212332720",
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      "id": "19a474a9-dd4a-89f0-6e2b-91f212332720",
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab" ]
      },
      "status": "final",
      "category": [ {
        "coding": [ {
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "2093-3",
          "display": "Cholesterol [Mass/volume] in Serum or Plasma"
        } ],
        "text": "Cholesterol [Mass/volume] in Serum or Plasma"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
      },
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        "system": "http://unitsofmeasure.org",
        "code": "mg/dL"
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    },
    "request": {
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      "url": "Observation"
    }
  }, {
    "fullUrl": "urn:uuid:74ca97b2-7d03-c34c-7c5f-f761ea3dfbc6",
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      "id": "74ca97b2-7d03-c34c-7c5f-f761ea3dfbc6",
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab" ]
      },
      "status": "final",
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "2571-8",
          "display": "Triglycerides"
        } ],
        "text": "Triglycerides"
      },
      "subject": {
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      },
      "encounter": {
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        "code": "mg/dL"
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    },
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      "url": "Observation"
    }
  }, {
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "18262-6",
          "display": "Low Density Lipoprotein Cholesterol"
        } ],
        "text": "Low Density Lipoprotein Cholesterol"
      },
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        "code": "mg/dL"
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      "url": "Observation"
    }
  }, {
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      "id": "5002e8d7-3054-d4ab-72f9-ef783c450f30",
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      },
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      "category": [ {
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "2085-9",
          "display": "Cholesterol in HDL [Mass/volume] in Serum or Plasma"
        } ],
        "text": "Cholesterol in HDL [Mass/volume] in Serum or Plasma"
      },
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    }
  }, {
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      "id": "5c4415a7-2d06-a6cb-438c-9fcf044f1400",
      "meta": {
        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-social-history" ]
      },
      "status": "final",
      "category": [ {
        "coding": [ {
          "system": "http://terminology.hl7.org/CodeSystem/observation-category",
          "code": "social-history",
          "display": "Social history"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "72166-2",
          "display": "Tobacco smoking status"
        } ],
        "text": "Tobacco smoking status"
      },
      "subject": {
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        "coding": [ {
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          "code": "8517006",
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        } ],
        "text": "Ex-smoker (finding)"
      }
    },
    "request": {
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      "url": "Observation"
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  }, {
    "fullUrl": "urn:uuid:5fa1f57c-206a-9b57-70d6-eaf1412282b3",
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
      },
      "status": "final",
      "category": [ {
        "coding": [ {
          "system": "http://terminology.hl7.org/CodeSystem/observation-category",
          "code": "survey",
          "display": "Survey"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "93025-5",
          "display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
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            "display": "Within the last year, have you been afraid of your partner or ex-partner?"
          } ],
          "text": "Within the last year, have you been afraid of your partner or ex-partner?"
        },
        "valueCodeableConcept": {
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          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "93026-3",
            "display": "Do you feel physically and emotionally safe where you currently live?"
          } ],
          "text": "Do you feel physically and emotionally safe where you currently live?"
        },
        "valueCodeableConcept": {
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          "text": "Yes"
        }
      }, {
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          "coding": [ {
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            "code": "93027-1",
            "display": "Are you a refugee?"
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          "text": "Are you a refugee?"
        },
        "valueCodeableConcept": {
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          } ],
          "text": "No"
        }
      }, {
        "code": {
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            "code": "93028-9",
            "display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
          } ],
          "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
        },
        "valueCodeableConcept": {
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            "display": "Yes"
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          "text": "Yes"
        }
      }, {
        "code": {
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          } ],
          "text": "Stress level"
        },
        "valueCodeableConcept": {
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          "text": "Quite a bit"
        }
      }, {
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            "code": "93029-7",
            "display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
          } ],
          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
        },
        "valueCodeableConcept": {
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        }
      }, {
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            "display": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
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          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
        },
        "valueCodeableConcept": {
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          } ],
          "text": "No"
        }
      }, {
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          "coding": [ {
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            "display": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
          } ],
          "text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
        },
        "valueCodeableConcept": {
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          "text": "I choose not to answer this question"
        }
      }, {
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            "code": "63586-2",
            "display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
          } ],
          "text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
        },
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          "coding": [ {
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            "code": "76437-3",
            "display": "Primary insurance"
          } ],
          "text": "Primary insurance"
        },
        "valueCodeableConcept": {
          "coding": [ {
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            "code": "LA15652-3",
            "display": "Medicare"
          } ],
          "text": "Medicare"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "67875-5",
            "display": "Employment status - current"
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          "text": "Employment status - current"
        },
        "valueCodeableConcept": {
          "coding": [ {
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            "code": "LA30136-8",
            "display": "Full-time work"
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          "text": "Full-time work"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "82589-3",
            "display": "Highest level of education"
          } ],
          "text": "Highest level of education"
        },
        "valueCodeableConcept": {
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            "code": "LA30191-3",
            "display": "Less than high school degree"
          } ],
          "text": "Less than high school degree"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "56799-0",
            "display": "Address"
          } ],
          "text": "Address"
        },
        "valueString": "318 Goldner Fork Unit 86"
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93033-9",
            "display": "Are you worried about losing your housing?"
          } ],
          "text": "Are you worried about losing your housing?"
        },
        "valueCodeableConcept": {
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            "code": "LA33-6",
            "display": "Yes"
          } ],
          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "71802-3",
            "display": "Housing status"
          } ],
          "text": "Housing status"
        },
        "valueCodeableConcept": {
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            "code": "LA30189-7",
            "display": "I have housing"
          } ],
          "text": "I have housing"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "63512-8",
            "display": "How many people are living or staying at this address?"
          } ],
          "text": "How many people are living or staying at this address?"
        },
        "valueQuantity": {
          "value": 8,
          "unit": "{#}",
          "system": "http://unitsofmeasure.org",
          "code": "{#}"
        }
      }, {
        "code": {
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            "code": "54899-0",
            "display": "Preferred language"
          } ],
          "text": "Preferred language"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA43-5",
            "display": "English"
          } ],
          "text": "English"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93034-7",
            "display": "Have you been discharged from the armed forces of the United States?"
          } ],
          "text": "Have you been discharged from the armed forces of the United States?"
        },
        "valueCodeableConcept": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "LA32-8",
            "display": "No"
          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93035-4",
            "display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
          } ],
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          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
        },
        "valueCodeableConcept": {
          "coding": [ {
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        }
      }, {
        "code": {
          "coding": [ {
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          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
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          "text": "No"
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          "text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
        },
        "valueCodeableConcept": {
          "coding": [ {
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          "text": "I choose not to answer this question"
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        "code": {
          "coding": [ {
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          "text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
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          "text": "Primary insurance"
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          "coding": [ {
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          "text": "Medicare"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "67875-5",
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          "text": "Employment status - current"
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          "text": "Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)"
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        "code": {
          "coding": [ {
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          "text": "Highest level of education"
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          "coding": [ {
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          "text": "Less than high school degree"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "56799-0",
            "display": "Address"
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          "text": "Address"
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          "coding": [ {
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          "text": "Are you worried about losing your housing?"
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      }, {
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          "coding": [ {
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          "text": "English"
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        "code": {
          "coding": [ {
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            "code": "93034-7",
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          "text": "Have you been discharged from the armed forces of the United States?"
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          "text": "No"
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      }, {
        "code": {
          "coding": [ {
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            "display": "Race"
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          "text": "Race"
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        "valueCodeableConcept": {
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          "text": "White"
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        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "56051-6",
            "display": "Do you consider yourself Hispanic/Latino?"
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          "text": "Do you consider yourself Hispanic/Latino?"
        },
        "valueCodeableConcept": {
          "coding": [ {
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          "text": "No"
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          "code": "70274-6",
          "display": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
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        "text": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
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        "text": "Fall risk total [Morse Fall Scale]"
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        "text": "Fall risk level [Morse Fall Scale]"
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        "text": "Moderate Risk (MFS Score 25 - 45)"
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        "text": "Community"
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  }, {
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      } ],
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        "coding": [ {
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          "code": "6299-2",
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        } ],
        "text": "Urea nitrogen [Mass/volume] in Blood"
      },
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      } ],
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          "code": "38483-4",
          "display": "Creatinine [Mass/volume] in Blood"
        } ],
        "text": "Creatinine [Mass/volume] in Blood"
      },
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    },
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  }, {
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      },
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        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "49765-1",
          "display": "Calcium [Mass/volume] in Blood"
        } ],
        "text": "Calcium [Mass/volume] in Blood"
      },
      "subject": {
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      },
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    },
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  }, {
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      },
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        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "2947-0",
          "display": "Sodium [Moles/volume] in Blood"
        } ],
        "text": "Sodium [Moles/volume] in Blood"
      },
      "subject": {
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      },
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        "system": "http://unitsofmeasure.org",
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    },
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      "url": "Observation"
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  }, {
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      },
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      } ],
      "code": {
        "coding": [ {
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          "code": "6298-4",
          "display": "Potassium [Moles/volume] in Blood"
        } ],
        "text": "Potassium [Moles/volume] in Blood"
      },
      "subject": {
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      },
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  }, {
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          "display": "Laboratory"
        } ]
      } ],
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        "coding": [ {
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          "code": "2069-3",
          "display": "Chloride [Moles/volume] in Blood"
        } ],
        "text": "Chloride [Moles/volume] in Blood"
      },
      "subject": {
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  }, {
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      },
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      "category": [ {
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "20565-8",
          "display": "Carbon dioxide, total [Moles/volume] in Blood"
        } ],
        "text": "Carbon dioxide, total [Moles/volume] in Blood"
      },
      "subject": {
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  }, {
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      "meta": {
        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-social-history" ]
      },
      "status": "final",
      "category": [ {
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          "code": "social-history",
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        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "72166-2",
          "display": "Tobacco smoking status"
        } ],
        "text": "Tobacco smoking status"
      },
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          "code": "8517006",
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        "text": "Ex-smoker (finding)"
      }
    },
    "request": {
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  }, {
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
      },
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          "code": "survey",
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        } ]
      } ],
      "code": {
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          "code": "93025-5",
          "display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
      },
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          "text": "Within the last year, have you been afraid of your partner or ex-partner?"
        },
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          "text": "No"
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      }, {
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          "text": "Do you feel physically and emotionally safe where you currently live?"
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      }, {
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          "text": "Are you a refugee?"
        },
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          "text": "No"
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      }, {
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            "display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
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          "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
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          "text": "Yes"
        }
      }, {
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          "text": "Stress level"
        },
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          "text": "A little bit"
        }
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          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
        },
        "valueCodeableConcept": {
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      }, {
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          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
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          "text": "No"
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        },
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          "text": "Primary insurance"
        },
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          "text": "Medicare"
        }
      }, {
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          "coding": [ {
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            "code": "67875-5",
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          "text": "Employment status - current"
        },
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          "text": "Full-time work"
        }
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            "display": "Highest level of education"
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          "text": "Highest level of education"
        },
        "valueCodeableConcept": {
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          "text": "Less than high school degree"
        }
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            "code": "56799-0",
            "display": "Address"
          } ],
          "text": "Address"
        },
        "valueString": "318 Goldner Fork Unit 86"
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          } ],
          "text": "Are you worried about losing your housing?"
        },
        "valueCodeableConcept": {
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          "text": "Yes"
        }
      }, {
        "code": {
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            "code": "71802-3",
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          "text": "Housing status"
        },
        "valueCodeableConcept": {
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            "display": "I have housing"
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          "text": "I have housing"
        }
      }, {
        "code": {
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            "code": "63512-8",
            "display": "How many people are living or staying at this address?"
          } ],
          "text": "How many people are living or staying at this address?"
        },
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          "text": "Preferred language"
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        "valueCodeableConcept": {
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          "text": "English"
        }
      }, {
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            "code": "93034-7",
            "display": "Have you been discharged from the armed forces of the United States?"
          } ],
          "text": "Have you been discharged from the armed forces of the United States?"
        },
        "valueCodeableConcept": {
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            "display": "No"
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          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
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        "coding": [ {
          "system": "http://terminology.hl7.org/CodeSystem/observation-category",
          "code": "social-history",
          "display": "Social history"
        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "72166-2",
          "display": "Tobacco smoking status"
        } ],
        "text": "Tobacco smoking status"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
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        "coding": [ {
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        "text": "Ex-smoker (finding)"
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    },
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          "system": "http://terminology.hl7.org/CodeSystem/observation-category",
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      } ],
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        "coding": [ {
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        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
      },
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          "text": "Within the last year, have you been afraid of your partner or ex-partner?"
        },
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          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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          } ],
          "text": "Do you feel physically and emotionally safe where you currently live?"
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          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
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          "text": "Are you a refugee?"
        },
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          "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
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          "text": "Yes"
        }
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          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
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          "text": "Highest level of education"
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          "text": "Are you worried about losing your housing?"
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          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
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          "text": "Race"
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          "text": "Do you consider yourself Hispanic/Latino?"
        },
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        "text": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
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        "text": "Fall risk total [Morse Fall Scale]"
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        "text": "Fall risk level [Morse Fall Scale]"
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      "code": {
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        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
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          "display": "Laboratory"
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      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "2069-3",
          "display": "Chloride [Moles/volume] in Blood"
        } ],
        "text": "Chloride [Moles/volume] in Blood"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
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        "coding": [ {
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          "code": "20565-8",
          "display": "Carbon dioxide, total [Moles/volume] in Blood"
        } ],
        "text": "Carbon dioxide, total [Moles/volume] in Blood"
      },
      "subject": {
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      "status": "final",
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        "coding": [ {
          "system": "http://terminology.hl7.org/CodeSystem/observation-category",
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          "display": "Social history"
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      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "72166-2",
          "display": "Tobacco smoking status"
        } ],
        "text": "Tobacco smoking status"
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        "coding": [ {
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        "text": "Ex-smoker (finding)"
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    },
    "request": {
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      "url": "Observation"
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        "coding": [ {
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          "display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
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            "system": "http://loinc.org",
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          "text": "Within the last year, have you been afraid of your partner or ex-partner?"
        },
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          "text": "No"
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      }, {
        "code": {
          "coding": [ {
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          "text": "Do you feel physically and emotionally safe where you currently live?"
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          "text": "Yes"
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      }, {
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          "text": "Are you a refugee?"
        },
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          "text": "No"
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          "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
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          "text": "Yes"
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      }, {
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          "text": "Stress level"
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        }
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          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
        },
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          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
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          "text": "No"
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        },
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          "text": "I choose not to answer this question"
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          "text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
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          "text": "Primary insurance"
        },
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          "text": "Medicare"
        }
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          "coding": [ {
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          "text": "Employment status - current"
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          "text": "Part-time or temporary work"
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        "code": {
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          "text": "Highest level of education"
        },
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          "text": "Less than high school degree"
        }
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          "text": "Address"
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        "valueString": "318 Goldner Fork Unit 86"
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          "text": "Are you worried about losing your housing?"
        },
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          "text": "Yes"
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          "text": "Housing status"
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          "text": "I have housing"
        }
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            "display": "How many people are living or staying at this address?"
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          "text": "How many people are living or staying at this address?"
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          "text": "English"
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          "text": "Have you been discharged from the armed forces of the United States?"
        },
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            "display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
          } ],
          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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          "text": "Race"
        },
        "valueCodeableConcept": {
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          "text": "White"
        }
      }, {
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          "coding": [ {
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            "display": "Do you consider yourself Hispanic/Latino?"
          } ],
          "text": "Do you consider yourself Hispanic/Latino?"
        },
        "valueCodeableConcept": {
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          "text": "No"
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      } ],
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        "text": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
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      } ],
      "code": {
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        "text": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
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      "code": {
        "coding": [ {
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          "code": "75626-2",
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        "text": "Total score [AUDIT-C]"
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        "text": "Assessment of health and social care needs (procedure)"
      },
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    },
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    }
  }, {
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      "status": "final",
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      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "6298-4",
          "display": "Potassium [Moles/volume] in Blood"
        } ],
        "text": "Potassium [Moles/volume] in Blood"
      },
      "subject": {
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        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "2069-3",
          "display": "Chloride [Moles/volume] in Blood"
        } ],
        "text": "Chloride [Moles/volume] in Blood"
      },
      "subject": {
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  }, {
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      } ],
      "code": {
        "coding": [ {
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          "code": "20565-8",
          "display": "Carbon dioxide, total [Moles/volume] in Blood"
        } ],
        "text": "Carbon dioxide, total [Moles/volume] in Blood"
      },
      "subject": {
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  }, {
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-social-history" ]
      },
      "status": "final",
      "category": [ {
        "coding": [ {
          "system": "http://terminology.hl7.org/CodeSystem/observation-category",
          "code": "social-history",
          "display": "Social history"
        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "72166-2",
          "display": "Tobacco smoking status"
        } ],
        "text": "Tobacco smoking status"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
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      "encounter": {
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        "coding": [ {
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          "code": "8517006",
          "display": "Ex-smoker (finding)"
        } ],
        "text": "Ex-smoker (finding)"
      }
    },
    "request": {
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  }, {
    "fullUrl": "urn:uuid:48571c1e-6ab5-d52d-1428-1dafbe033c7b",
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
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      "status": "final",
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        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "93025-5",
          "display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
      },
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          "coding": [ {
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            "display": "Within the last year, have you been afraid of your partner or ex-partner?"
          } ],
          "text": "Within the last year, have you been afraid of your partner or ex-partner?"
        },
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          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "93026-3",
            "display": "Do you feel physically and emotionally safe where you currently live?"
          } ],
          "text": "Do you feel physically and emotionally safe where you currently live?"
        },
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          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "93027-1",
            "display": "Are you a refugee?"
          } ],
          "text": "Are you a refugee?"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
      }, {
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            "display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
          } ],
          "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
        },
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          } ],
          "text": "Yes"
        }
      }, {
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          } ],
          "text": "Stress level"
        },
        "valueCodeableConcept": {
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          "text": "Not at all"
        }
      }, {
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            "display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
          } ],
          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
        },
        "valueCodeableConcept": {
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          "text": "5 or more times a week"
        }
      }, {
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          } ],
          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
      }, {
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          "coding": [ {
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            "display": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
          } ],
          "text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
        },
        "valueCodeableConcept": {
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            "display": "Medicine or Any Health Care (Medical, Dental, Mental Health, Vision)"
          } ],
          "text": "Medicine or Any Health Care (Medical, Dental, Mental Health, Vision)"
        }
      }, {
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          "coding": [ {
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            "code": "63586-2",
            "display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
          } ],
          "text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
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          "text": "Primary insurance"
        },
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          } ],
          "text": "Medicare"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "67875-5",
            "display": "Employment status - current"
          } ],
          "text": "Employment status - current"
        },
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            "code": "LA30136-8",
            "display": "Full-time work"
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          "text": "Full-time work"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "82589-3",
            "display": "Highest level of education"
          } ],
          "text": "Highest level of education"
        },
        "valueCodeableConcept": {
          "coding": [ {
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            "code": "LA30191-3",
            "display": "Less than high school degree"
          } ],
          "text": "Less than high school degree"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "56799-0",
            "display": "Address"
          } ],
          "text": "Address"
        },
        "valueString": "318 Goldner Fork Unit 86"
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          "coding": [ {
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            "code": "93033-9",
            "display": "Are you worried about losing your housing?"
          } ],
          "text": "Are you worried about losing your housing?"
        },
        "valueCodeableConcept": {
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            "code": "LA33-6",
            "display": "Yes"
          } ],
          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "71802-3",
            "display": "Housing status"
          } ],
          "text": "Housing status"
        },
        "valueCodeableConcept": {
          "coding": [ {
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            "display": "I have housing"
          } ],
          "text": "I have housing"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "63512-8",
            "display": "How many people are living or staying at this address?"
          } ],
          "text": "How many people are living or staying at this address?"
        },
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          "text": "Preferred language"
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        "valueCodeableConcept": {
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            "code": "LA43-5",
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          "text": "English"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "93034-7",
            "display": "Have you been discharged from the armed forces of the United States?"
          } ],
          "text": "Have you been discharged from the armed forces of the United States?"
        },
        "valueCodeableConcept": {
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            "code": "LA32-8",
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          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93035-4",
            "display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
          } ],
          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
        },
        "valueCodeableConcept": {
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            "display": "No"
          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "32624-9",
            "display": "Race"
          } ],
          "text": "Race"
        },
        "valueCodeableConcept": {
          "coding": [ {
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            "code": "LA4457-3",
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          } ],
          "text": "White"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "56051-6",
            "display": "Do you consider yourself Hispanic/Latino?"
          } ],
          "text": "Do you consider yourself Hispanic/Latino?"
        },
        "valueCodeableConcept": {
          "coding": [ {
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            "code": "LA32-8",
            "display": "No"
          } ],
          "text": "No"
        }
      } ]
    },
    "request": {
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      "url": "Observation"
    }
  }, {
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      "resourceType": "Observation",
      "id": "787458a4-f884-cf3a-fd97-a1649e3328c2",
      "meta": {
        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
      },
      "status": "final",
      "category": [ {
        "coding": [ {
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          "code": "survey",
          "display": "Survey"
        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "70274-6",
          "display": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
        } ],
        "text": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
      },
      "subject": {
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        "reference": "urn:uuid:d203e6ee-65b5-73cb-cf52-43d3df65da72"
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        "value": 3,
        "unit": "{score}",
        "system": "http://unitsofmeasure.org",
        "code": "{score}"
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    },
    "request": {
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      "url": "Observation"
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  }, {
    "fullUrl": "urn:uuid:6d8ed3f8-db88-c36d-dee2-5125eef430a7",
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      "resourceType": "Observation",
      "id": "6d8ed3f8-db88-c36d-dee2-5125eef430a7",
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
      },
      "status": "final",
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          "display": "Survey"
        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "59460-6",
          "display": "Fall risk total [Morse Fall Scale]"
        } ],
        "text": "Fall risk total [Morse Fall Scale]"
      },
      "subject": {
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      "encounter": {
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    "request": {
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  }, {
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      "resourceType": "Observation",
      "id": "906d5960-0e0f-d946-07e4-f1ac27ddca16",
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
      },
      "status": "final",
      "category": [ {
        "coding": [ {
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          "display": "Survey"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "59461-4",
          "display": "Fall risk level [Morse Fall Scale]"
        } ],
        "text": "Fall risk level [Morse Fall Scale]"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
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      "valueCodeableConcept": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "LA13040-3",
          "display": "High Risk (MFS Score 50+)"
        } ],
        "text": "High Risk (MFS Score 50+)"
      }
    },
    "request": {
      "method": "POST",
      "url": "Observation"
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  }, {
    "fullUrl": "urn:uuid:034a3717-deb3-31ea-6e35-a5ccc53a88e1",
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      "id": "034a3717-deb3-31ea-6e35-a5ccc53a88e1",
      "meta": {
        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
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      "meta": {
        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab" ]
      },
      "status": "final",
      "category": [ {
        "coding": [ {
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "2571-8",
          "display": "Triglycerides"
        } ],
        "text": "Triglycerides"
      },
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    },
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      "url": "Observation"
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  }, {
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab" ]
      },
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "18262-6",
          "display": "Low Density Lipoprotein Cholesterol"
        } ],
        "text": "Low Density Lipoprotein Cholesterol"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
      },
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    },
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      "url": "Observation"
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  }, {
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      },
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          "display": "Laboratory"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "2085-9",
          "display": "Cholesterol in HDL [Mass/volume] in Serum or Plasma"
        } ],
        "text": "Cholesterol in HDL [Mass/volume] in Serum or Plasma"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
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  }, {
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      "meta": {
        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-social-history" ]
      },
      "status": "final",
      "category": [ {
        "coding": [ {
          "system": "http://terminology.hl7.org/CodeSystem/observation-category",
          "code": "social-history",
          "display": "Social history"
        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "72166-2",
          "display": "Tobacco smoking status"
        } ],
        "text": "Tobacco smoking status"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
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        "coding": [ {
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          "code": "8517006",
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        "text": "Ex-smoker (finding)"
      }
    },
    "request": {
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    }
  }, {
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
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          "code": "survey",
          "display": "Survey"
        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "93025-5",
          "display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
      },
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        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
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          "coding": [ {
            "system": "http://loinc.org",
            "code": "76501-6",
            "display": "Within the last year, have you been afraid of your partner or ex-partner?"
          } ],
          "text": "Within the last year, have you been afraid of your partner or ex-partner?"
        },
        "valueCodeableConcept": {
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            "code": "LA32-8",
            "display": "No"
          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "93026-3",
            "display": "Do you feel physically and emotionally safe where you currently live?"
          } ],
          "text": "Do you feel physically and emotionally safe where you currently live?"
        },
        "valueCodeableConcept": {
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          } ],
          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93027-1",
            "display": "Are you a refugee?"
          } ],
          "text": "Are you a refugee?"
        },
        "valueCodeableConcept": {
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          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "93028-9",
            "display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
          } ],
          "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
        },
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          "coding": [ {
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          } ],
          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
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          } ],
          "text": "Stress level"
        },
        "valueCodeableConcept": {
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            "code": "LA13909-9",
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          } ],
          "text": "Somewhat"
        }
      }, {
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          "coding": [ {
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            "code": "93029-7",
            "display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
          } ],
          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
        },
        "valueCodeableConcept": {
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          "text": "3 to 5 times a week"
        }
      }, {
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          } ],
          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
        },
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          "text": "No"
        }
      }, {
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          "coding": [ {
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            "display": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
          } ],
          "text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
        },
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          "text": "I choose not to answer this question"
        }
      }, {
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            "display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
          } ],
          "text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
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          "text": "Primary insurance"
        },
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            "code": "LA15652-3",
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          "text": "Medicare"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "67875-5",
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          "text": "Employment status - current"
        },
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          "coding": [ {
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            "display": "Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)"
          } ],
          "text": "Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "82589-3",
            "display": "Highest level of education"
          } ],
          "text": "Highest level of education"
        },
        "valueCodeableConcept": {
          "coding": [ {
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            "code": "LA30191-3",
            "display": "Less than high school degree"
          } ],
          "text": "Less than high school degree"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "56799-0",
            "display": "Address"
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          "text": "Address"
        },
        "valueString": "318 Goldner Fork Unit 86"
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          "coding": [ {
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            "code": "93033-9",
            "display": "Are you worried about losing your housing?"
          } ],
          "text": "Are you worried about losing your housing?"
        },
        "valueCodeableConcept": {
          "coding": [ {
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            "display": "Yes"
          } ],
          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "71802-3",
            "display": "Housing status"
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          "text": "Housing status"
        },
        "valueCodeableConcept": {
          "coding": [ {
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            "code": "LA30189-7",
            "display": "I have housing"
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          "text": "I have housing"
        }
      }, {
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          "coding": [ {
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            "display": "How many people are living or staying at this address?"
          } ],
          "text": "How many people are living or staying at this address?"
        },
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          "text": "Preferred language"
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          "text": "English"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "93034-7",
            "display": "Have you been discharged from the armed forces of the United States?"
          } ],
          "text": "Have you been discharged from the armed forces of the United States?"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "93035-4",
            "display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
          } ],
          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
        },
        "valueCodeableConcept": {
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          } ],
          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "32624-9",
            "display": "Race"
          } ],
          "text": "Race"
        },
        "valueCodeableConcept": {
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          } ],
          "text": "White"
        }
      }, {
        "code": {
          "coding": [ {
            "system": "http://loinc.org",
            "code": "56051-6",
            "display": "Do you consider yourself Hispanic/Latino?"
          } ],
          "text": "Do you consider yourself Hispanic/Latino?"
        },
        "valueCodeableConcept": {
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          } ],
          "text": "No"
        }
      } ]
    },
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  }, {
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      "id": "540eb69e-f70a-cff1-dbf7-8956bceeb293",
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      },
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        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
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          "display": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
        } ],
        "text": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
      },
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    },
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  }, {
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        } ]
      } ],
      "code": {
        "coding": [ {
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          "display": "Fall risk total [Morse Fall Scale]"
        } ],
        "text": "Fall risk total [Morse Fall Scale]"
      },
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  }, {
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        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "59461-4",
          "display": "Fall risk level [Morse Fall Scale]"
        } ],
        "text": "Fall risk level [Morse Fall Scale]"
      },
      "subject": {
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        } ],
        "text": "Low Risk (MFS Score 0 - 24)"
      }
    },
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  }, {
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        } ]
      } ],
      "code": {
        "coding": [ {
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          "code": "2069-3",
          "display": "Chloride [Moles/volume] in Blood"
        } ],
        "text": "Chloride [Moles/volume] in Blood"
      },
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        } ]
      } ],
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        "coding": [ {
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          "code": "20565-8",
          "display": "Carbon dioxide, total [Moles/volume] in Blood"
        } ],
        "text": "Carbon dioxide, total [Moles/volume] in Blood"
      },
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      },
      "status": "final",
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        "coding": [ {
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          "code": "social-history",
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        } ]
      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "72166-2",
          "display": "Tobacco smoking status"
        } ],
        "text": "Tobacco smoking status"
      },
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        "coding": [ {
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        "text": "Ex-smoker (finding)"
      }
    },
    "request": {
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  }, {
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      } ],
      "code": {
        "coding": [ {
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          "code": "93025-5",
          "display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
      },
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          "coding": [ {
            "system": "http://loinc.org",
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          } ],
          "text": "Within the last year, have you been afraid of your partner or ex-partner?"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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            "code": "93026-3",
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          } ],
          "text": "Do you feel physically and emotionally safe where you currently live?"
        },
        "valueCodeableConcept": {
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          "text": "Yes"
        }
      }, {
        "code": {
          "coding": [ {
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            "display": "Are you a refugee?"
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          "text": "Are you a refugee?"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
      }, {
        "code": {
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          } ],
          "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
        },
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          "text": "Yes"
        }
      }, {
        "code": {
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          "text": "Stress level"
        },
        "valueCodeableConcept": {
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          "text": "Somewhat"
        }
      }, {
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          } ],
          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
        },
        "valueCodeableConcept": {
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          "text": "3 to 5 times a week"
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          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
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          "text": "No"
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        },
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          "text": "I choose not to answer this question"
        }
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          "text": "Primary insurance"
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          "text": "Medicare"
        }
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          "coding": [ {
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          "text": "Employment status - current"
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          "text": "Full-time work"
        }
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          "text": "Highest level of education"
        },
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          "text": "Less than high school degree"
        }
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        "code": {
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          "text": "Address"
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        "valueString": "318 Goldner Fork Unit 86"
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          "text": "Are you worried about losing your housing?"
        },
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          "text": "Yes"
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          "text": "Have you been discharged from the armed forces of the United States?"
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          } ],
          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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          "text": "Race"
        },
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          "text": "White"
        }
      }, {
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          "text": "Do you consider yourself Hispanic/Latino?"
        },
        "valueCodeableConcept": {
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          "text": "No"
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  }, {
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        "text": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
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      } ],
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        "text": "Fall risk total [Morse Fall Scale]"
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        "text": "Fall risk level [Morse Fall Scale]"
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        "text": "Moderate Risk (MFS Score 25 - 45)"
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      } ],
      "code": {
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          "display": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
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        "text": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
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  }, {
    "fullUrl": "urn:uuid:bfd50941-7268-3208-89a5-d058437d3a58",
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      } ],
      "code": {
        "coding": [ {
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          "code": "82667-7",
          "display": "Total score [DAST-10]"
        } ],
        "text": "Total score [DAST-10]"
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        "text": "Tobacco smoking status"
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        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
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          "text": "Employment status - current"
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          "text": "Do you consider yourself Hispanic/Latino?"
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          "display": "Laboratory"
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      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "2069-3",
          "display": "Chloride [Moles/volume] in Blood"
        } ],
        "text": "Chloride [Moles/volume] in Blood"
      },
      "subject": {
        "reference": "urn:uuid:ecf9d885-b712-e318-a6fa-f1ec9ffdbde8"
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      } ],
      "code": {
        "coding": [ {
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          "code": "20565-8",
          "display": "Carbon dioxide, total [Moles/volume] in Blood"
        } ],
        "text": "Carbon dioxide, total [Moles/volume] in Blood"
      },
      "subject": {
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      "status": "final",
      "category": [ {
        "coding": [ {
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          "code": "social-history",
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      } ],
      "code": {
        "coding": [ {
          "system": "http://loinc.org",
          "code": "72166-2",
          "display": "Tobacco smoking status"
        } ],
        "text": "Tobacco smoking status"
      },
      "subject": {
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        "coding": [ {
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          "code": "8517006",
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        "text": "Ex-smoker (finding)"
      }
    },
    "request": {
      "method": "POST",
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  }, {
    "fullUrl": "urn:uuid:02c1af7f-5530-4705-dd87-1942cb2481ad",
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      "status": "final",
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      } ],
      "code": {
        "coding": [ {
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          "code": "93025-5",
          "display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
        } ],
        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
      },
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          "coding": [ {
            "system": "http://loinc.org",
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          } ],
          "text": "Within the last year, have you been afraid of your partner or ex-partner?"
        },
        "valueCodeableConcept": {
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          "text": "No"
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      }, {
        "code": {
          "coding": [ {
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            "code": "93026-3",
            "display": "Do you feel physically and emotionally safe where you currently live?"
          } ],
          "text": "Do you feel physically and emotionally safe where you currently live?"
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      }, {
        "code": {
          "coding": [ {
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            "display": "Are you a refugee?"
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          "text": "Are you a refugee?"
        },
        "valueCodeableConcept": {
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          "text": "No"
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      }, {
        "code": {
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          "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
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          "text": "Yes"
        }
      }, {
        "code": {
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          "text": "Stress level"
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        "valueCodeableConcept": {
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        }
      }, {
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            "display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
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          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
        },
        "valueCodeableConcept": {
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          "text": "3 to 5 times a week"
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      }, {
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          "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
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        "valueCodeableConcept": {
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          "text": "No"
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          "text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
        },
        "valueCodeableConcept": {
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          "text": "I choose not to answer this question"
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      }, {
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          "text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
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          "text": "Primary insurance"
        },
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          "text": "Medicare"
        }
      }, {
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          "coding": [ {
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          "text": "Employment status - current"
        },
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          "text": "Part-time or temporary work"
        }
      }, {
        "code": {
          "coding": [ {
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            "display": "Highest level of education"
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          "text": "Highest level of education"
        },
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          "text": "Less than high school degree"
        }
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        "code": {
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          "text": "Address"
        },
        "valueString": "318 Goldner Fork Unit 86"
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          "text": "Are you worried about losing your housing?"
        },
        "valueCodeableConcept": {
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          "text": "Yes"
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        "code": {
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          "text": "Housing status"
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        "valueCodeableConcept": {
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          "text": "I have housing"
        }
      }, {
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            "display": "How many people are living or staying at this address?"
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          "text": "How many people are living or staying at this address?"
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          "text": "English"
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          "coding": [ {
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          "text": "Have you been discharged from the armed forces of the United States?"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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            "display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
          } ],
          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
        },
        "valueCodeableConcept": {
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          "text": "No"
        }
      }, {
        "code": {
          "coding": [ {
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            "display": "Race"
          } ],
          "text": "Race"
        },
        "valueCodeableConcept": {
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          "text": "White"
        }
      }, {
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          "coding": [ {
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            "display": "Do you consider yourself Hispanic/Latino?"
          } ],
          "text": "Do you consider yourself Hispanic/Latino?"
        },
        "valueCodeableConcept": {
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          "text": "No"
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    },
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  }, {
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      } ],
      "code": {
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          "display": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
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        "text": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
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        "text": "Total score [DAST-10]"
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  }, {
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        "text": "Assessment of health and social care needs (procedure)"
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      "status": "completed",
      "code": {
        "coding": [ {
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          "code": "171207006",
          "display": "Depression screening (procedure)"
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        "text": "Depression screening (procedure)"
      },
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        "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure" ]
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        "text": "Calcium [Mass/volume] in Blood"
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        "text": "Sodium [Moles/volume] in Blood"
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        "text": "Potassium [Moles/volume] in Blood"
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        "text": "Chloride [Moles/volume] in Blood"
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      } ],
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        "text": "Tobacco smoking status"
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          "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
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          "text": "Highest level of education"
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          "text": "Address"
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          "text": "Are you worried about losing your housing?"
        },
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          "text": "Have you been discharged from the armed forces of the United States?"
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        "valueCodeableConcept": {
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        }
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            "display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
          } ],
          "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
        },
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          "text": "No"
        }
      }, {
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          } ],
          "text": "Race"
        },
        "valueCodeableConcept": {
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          } ],
          "text": "White"
        }
      }, {
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          "coding": [ {
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            "code": "56051-6",
            "display": "Do you consider yourself Hispanic/Latino?"
          } ],
          "text": "Do you consider yourself Hispanic/Latino?"
        },
        "valueCodeableConcept": {
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            "code": "LA32-8",
            "display": "No"
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          "text": "No"
        }
      } ]
    },
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  }, {
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        "text": "Tobacco smoking status"
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        "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
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        "code": {
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        "code": {
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          "text": "Do you consider yourself Hispanic/Latino?"
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        "text": "Total score [HARK]"
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        "text": "Patient Health Questionnaire 9 item (PHQ-9) total score [Reported]"
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