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Accepted chart labels
Human-confirmed labels that stay on the chart after a cohort membership is accepted.
0, active
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Cohort memberships
Patient-list membership from saved cohort runs. These are source lists, not task status or accepted chart labels.
2, current
Frailty / Falls review cohort
Chart evidence: Flag: diabetes_prediabetes prediabetes_risk medium new Prediabetes range HbA1c Latest HbA1c 6.1% falls in the prediabetes range without a diabetes problem-list dia...
membership needs review
No review task has been created from this cohort for this patient yet.
Smoking / Lung Screening review cohort
Chart evidence: Care element: smoking_status former smoker form
membership needs review
Open review tasks
3
New, in review, or accepted tasks
Last visit
2026-03-14
Appointment or derived chart contact
Latest A1c
6.1 %
2026-04-19
Latest BP
134 mmHg / 78 mmHg
2025-04-25
Extracted signals
0
Optional text signals
Chart volume
25
5 notes, 1 reports
A compact view of what needs attention before opening the full imported record.
Review priority
1
active signal
3
0
0
Review these before relying on the imported record clinically.
Review needed
3 open flags
Open clinical review items need status, assignment, or closure.
Active problems
4
Diabetic eye screening risk
active
Osteoarthritis of knee
M19.90
active
Mild cognitive impairment
G31.84
active
History of TIA/stroke
Z86.73
active
Active medications
2
Rosuvastatin
20 mg daily
ASA 81 mg
81 mg daily
No review task has been created from this cohort for this patient yet.
AI-CDS actions selected from Flags & Tasks. These stay visible on the chart for follow-up.
0, selected
No selected follow-up actions
Select AI-CDS actions from Flags & Tasks to keep them visible on this chart.
Saved population-health queue work for this patient: calls, recalls, flags, snoozes, exclusions, and completions.
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11, more source rows below
Latest narrative evidence, clipped for scanning.
Recent report headers and excerpts.
Audit view for imported records. Kept collapsed so the working chart remains usable.
PHM saved action
PHM action: DEMENTIA_CARE_PLAN_DUE
status=in_review | imported | outreach=phone 2026-04-12 17:10 | next review=2026-06-09 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient.
PHM saved action
PHM action: PREDIABETES_RISK
status=new | imported | outreach=phone 2026-03-11 15:40 | next review=2026-06-09 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: diabetes_prediabetes prediabetes_risk medium new Prediabetes range HbA1c Latest HbA1c 6.1% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Flag: dementia dementia_care_plan_due medium new Dementia care plan review Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. clinical_note | Clinical note: SOAP note Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status former smoker form | probable
phm_workflow
PHM action: DEMENTIA_CARE_PLAN_DUE
status=in_review | imported | outreach=phone 2026-04-12 17:10 | next review=2026-06-09 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient.
phm_workflow
PHM action: PREDIABETES_RISK
status=new | imported | outreach=phone 2026-03-11 15:40 | next review=2026-06-09 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient.
clinical_flag
Eye exam evidence missing or overdue
accepted | medium | active_cohort_automation | Diabetic eye screening risk is documented but no recent eye exam report is present in the synthetic chart.
clinical_flag
Dementia care plan review
new | medium | clinical_note | Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed.
clinical_flag
Prediabetes range HbA1c
new | medium | structured_fact | Latest HbA1c 6.1% falls in the prediabetes range without a diabetes problem-list diagnosis.
appointment
same-day concern
cancelled
note
SOAP note
MSK review: chronic knee pain with morning stiffness and crepitus, consistent with osteoarthritis pattern. Discussed activity modification, strengthening, topical/oral analgesia risks, imaging only if red flags or surgical planning.
note
preventive care
HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented.
appointment
periodic health review
completed
report
Consult
Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
note
SOAP note
Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports improving symptoms. Plan: update labs/vitals and arrange follow-up as clinically indicated.
note
SOAP note
Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
SOAP note
MSK review: chronic knee pain with morning stiffness and crepitus, consistent with osteoarthritis pattern. Discussed activity modification, strengthening, topical/oral analgesia risks, imaging only if red flags or surgical planning.
preventive care
HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented.
SOAP note
Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports improving symptoms. Plan: update labs/vitals and arrange follow-up as clinically indicated.
SOAP note
Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
Consult
Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
Eye exam evidence missing or overdue
Diabetic eye screening risk is documented but no recent eye exam report is present in the synthetic chart.
Dementia care plan review
Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed.
Prediabetes range HbA1c
Latest HbA1c 6.1% falls in the prediabetes range without a diabetes problem-list diagnosis.
Hba1c
6.1 %
2026-04-19Diastolic Bp
78 mmHg
2025-04-25Systolic Bp
134 mmHg
2025-04-25Bmi
25.9 kg/m2
2024-11-03Smoking Status
former smoker
2024-09-27Diastolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: diabetes_prediabetes prediabetes_risk medium new Prediabetes range HbA1c Latest HbA1c 6.1% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Flag: dementia dementia_care_plan_due medium new Dementia care plan review Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. clinical_note | Clinical note: SOAP note Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status former smoker form | probable | |
phm_workflow | PHM action: DEMENTIA_CARE_PLAN_DUE | status=in_review | imported | outreach=phone 2026-04-12 17:10 | next review=2026-06-09 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: PREDIABETES_RISK | status=new | imported | outreach=phone 2026-03-11 15:40 | next review=2026-06-09 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient. | |
clinical_flag | Eye exam evidence missing or overdue | accepted | medium | active_cohort_automation | Diabetic eye screening risk is documented but no recent eye exam report is present in the synthetic chart. | |
clinical_flag | Dementia care plan review | new | medium | clinical_note | Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. | |
clinical_flag | Prediabetes range HbA1c | new | medium | structured_fact | Latest HbA1c 6.1% falls in the prediabetes range without a diabetes problem-list diagnosis. | |
care_element | hba1c | ||
appointment | same-day concern | cancelled | |
note | SOAP note | MSK review: chronic knee pain with morning stiffness and crepitus, consistent with osteoarthritis pattern. Discussed activity modification, strengthening, topical/oral analgesia risks, imaging only if red flags or surgical planning. | |
note | preventive care | HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented. | |
appointment | periodic health review | completed | |
report | Consult | Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed. | |
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports improving symptoms. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
note | SOAP note | Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
note | consult | History of TIA/stroke follow-up. Patient reports palpitations resolved. Plan: continue guideline-oriented risk management and monitor labs. | |
care_element | bmi | ||
care_element | smoking_status | former smoker | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | hba1c | ||
appointment | lab follow-up | completed | |
appointment | chronic disease review | completed |
64 mmHg
2024-09-26Systolic Bp
110 mmHg
2024-09-26Hba1c
6.2 %
2022-12-14