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1, current
Smoking / Lung Screening review cohort
Chart evidence: Care element: smoking_status never synthetic-demo | Clinical note: SOAP note Preventive care S: Patient seen for longitudinal primary care follow-up. Reports gener...
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1
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Last visit
2026-01-18
Appointment or derived chart contact
Latest A1c
5.2 %
2026-02-14
Latest BP
125 mmHg / 69 mmHg
2026-02-14
Extracted signals
0
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Chart volume
92
7 notes, 7 reports
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1
active signal
1
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1 open flag
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Active problems
1
Chronic kidney disease stage 3
N18.3
active
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1
Metformin
500mg BID
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cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status never synthetic-demo | Clinical note: SOAP note Preventive care S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 133/85, BMI 28.3, cardiopulmonary exam stable, feet c... | Clinical note: SOAP note Preventive care S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 132/84, BMI 27.3, cardiopulmonary exam stable, feet c... | Care element: smoking_status never synthetic-demo | probable
clinical_flag
Synthetic CKD surveillance review
new | high | synthetic_longitudinal_data | Synthetic eGFR/ACR trend suggests CKD surveillance should be reviewed.
note
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 133/85, BMI 28.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care
report
Laboratory
Lab panel: HbA1c 5.2%, LDL 3.4 mmol/L, eGFR 55, ACR 8.9. Interpret in clinical context.
appointment
Annual preventive visit
completed
appointment
Annual preventive visit
completed
appointment
Annual preventive visit
completed
note
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 132/84, BMI 27.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care
report
Laboratory
Lab panel: HbA1c 5.1%, LDL 3.3 mmol/L, eGFR 54, ACR 8.8. Interpret in clinical context.
note
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 131/83, BMI 26.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care
report
Laboratory
Lab panel: HbA1c 6.2%, LDL 3.2 mmol/L, eGFR 53, ACR 8.7. Interpret in clinical context.
appointment
Annual preventive visit
completed
appointment
Annual preventive visit
completed
note
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 130/82, BMI 25.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 133/85, BMI 28.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care review; CKD surveillance; risk factors reviewed. P: Review labs, reinforce lifestyle plan, reconcile medications, update immunizations, and arrange follow-up. Clinician review required for any care gap.
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 132/84, BMI 27.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care review; CKD surveillance; risk factors reviewed. P: Review labs, reinforce lifestyle plan, reconcile medications, update immunizations, and arrange follow-up. Clinician review required for any care gap.
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 131/83, BMI 26.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care review; CKD surveillance; risk factors reviewed. P: Review labs, reinforce lifestyle plan, reconcile medications, update immunizations, and arrange follow-up. Clinician review required for any care gap.
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 130/82, BMI 25.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care review; CKD surveillance; risk factors reviewed. P: Review labs, reinforce lifestyle plan, reconcile medications, update immunizations, and arrange follow-up. Clinician review required for any care gap.
Synthetic CKD surveillance review
Synthetic eGFR/ACR trend suggests CKD surveillance should be reviewed.
Laboratory
Lab panel: HbA1c 5.2%, LDL 3.4 mmol/L, eGFR 55, ACR 8.9. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 5.1%, LDL 3.3 mmol/L, eGFR 54, ACR 8.8. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 6.2%, LDL 3.2 mmol/L, eGFR 53, ACR 8.7. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 6.1%, LDL 3.1 mmol/L, eGFR 52, ACR 8.6. Interpret in clinical context.
Laboratory
Hba1c
5.2 %
2026-02-14Fasting Glucose
6.1 mmol/L
2026-02-14Ldl Cholesterol
3.4 mmol/L
2026-02-14Egfr
55 mL/min/1.73m2
2026-02-14Albumin Creatinine Ratio
8.9 mg/mmol
2026-02-14Systolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status never synthetic-demo | Clinical note: SOAP note Preventive care S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 133/85, BMI 28.3, cardiopulmonary exam stable, feet c... | Clinical note: SOAP note Preventive care S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 132/84, BMI 27.3, cardiopulmonary exam stable, feet c... | Care element: smoking_status never synthetic-demo | probable | |
clinical_flag | Synthetic CKD surveillance review | new | high | synthetic_longitudinal_data | Synthetic eGFR/ACR trend suggests CKD surveillance should be reviewed. | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 133/85, BMI 28.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care | |
report | Laboratory | Lab panel: HbA1c 5.2%, LDL 3.4 mmol/L, eGFR 55, ACR 8.9. Interpret in clinical context. | |
care_element | diastolic_bp | 69 | |
care_element | fasting_glucose | 6.1 | |
care_element | bmi | 31.3 | |
care_element | egfr | 55 | |
care_element | albumin_creatinine_ratio | 8.9 | |
care_element | smoking_status | never | |
care_element | ldl_cholesterol | 3.4 | |
care_element | systolic_bp | 125 | |
care_element | hba1c | 5.2 | |
appointment | Annual preventive visit | completed | |
appointment | Annual preventive visit | completed | |
appointment | Annual preventive visit | completed | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 132/84, BMI 27.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care | |
report | Laboratory | Lab panel: HbA1c 5.1%, LDL 3.3 mmol/L, eGFR 54, ACR 8.8. Interpret in clinical context. | |
care_element | egfr | 54 | |
care_element | systolic_bp | 124 | |
care_element | smoking_status | never | |
care_element | ldl_cholesterol | 3.3 | |
care_element | albumin_creatinine_ratio | 8.8 | |
care_element | hba1c | 5.1 | |
care_element | bmi | 30.3 | |
care_element | diastolic_bp | 68 | |
care_element | fasting_glucose | 6.0 | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 131/83, BMI 26.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care | |
report | Laboratory | Lab panel: HbA1c 6.2%, LDL 3.2 mmol/L, eGFR 53, ACR 8.7. Interpret in clinical context. | |
care_element | bmi | 29.3 | |
care_element | ldl_cholesterol | 3.2 | |
care_element | albumin_creatinine_ratio | 8.7 | |
care_element | fasting_glucose | 5.9 | |
care_element | smoking_status | never | |
care_element | egfr | 53 | |
care_element | systolic_bp | 123 | |
care_element | diastolic_bp | 80 | |
care_element | hba1c | 6.2 | |
appointment | Annual preventive visit | completed | |
appointment | Annual preventive visit | completed | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 130/82, BMI 25.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care | |
report | Laboratory | Lab panel: HbA1c 6.1%, LDL 3.1 mmol/L, eGFR 52, ACR 8.6. Interpret in clinical context. | |
care_element | diastolic_bp | 79 | |
care_element | fasting_glucose | 5.8 | |
care_element | ldl_cholesterol | 3.1 | |
care_element | smoking_status | never | |
care_element | systolic_bp | 122 | |
care_element | albumin_creatinine_ratio | 8.6 | |
care_element | bmi | 28.3 | |
care_element | hba1c | 6.1 | |
care_element | egfr | 52 | |
appointment | Annual preventive visit | completed | |
appointment | Annual preventive visit | completed | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 129/81, BMI 24.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care | |
report | Laboratory | Lab panel: HbA1c 6.0%, LDL 3.0 mmol/L, eGFR 51, ACR 8.5. Interpret in clinical context. | |
care_element | hba1c | 6.0 | |
care_element | systolic_bp | 121 | |
care_element | fasting_glucose | 5.7 | |
care_element | egfr | 51 | |
care_element | smoking_status | never | |
care_element | albumin_creatinine_ratio | 8.5 | |
care_element | diastolic_bp | 78 | |
care_element | ldl_cholesterol | 3.0 | |
care_element | bmi | 27.3 | |
appointment | Annual preventive visit | completed | |
appointment | Annual preventive visit | completed | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 128/80, BMI 23.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care | |
report | Laboratory | Lab panel: HbA1c 5.9%, LDL 2.9 mmol/L, eGFR 50, ACR 8.4. Interpret in clinical context. | |
care_element | ldl_cholesterol | 2.9 | |
care_element | diastolic_bp | 77 | |
care_element | hba1c | 5.9 | |
care_element | bmi | 26.3 | |
care_element | albumin_creatinine_ratio | 8.4 | |
care_element | smoking_status | never | |
care_element | egfr | 50 | |
care_element | systolic_bp | 120 | |
care_element | fasting_glucose | 5.6 | |
appointment | Annual preventive visit | completed | |
appointment | Annual preventive visit | completed | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with no major interval concerns. O: BP 127/79, BMI 36.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care | |
report | Laboratory | Lab panel: HbA1c 5.8%, LDL 2.8 mmol/L, eGFR 49, ACR 8.3. Interpret in clinical context. | |
care_element | diastolic_bp | 76 | |
care_element | fasting_glucose | 5.5 | |
care_element | bmi | 25.3 | |
care_element | egfr | 49 | |
care_element | smoking_status | never | |
care_element | hba1c | 5.8 | |
care_element | ldl_cholesterol | 2.8 | |
care_element | systolic_bp | 119 | |
care_element | albumin_creatinine_ratio | 8.3 | |
appointment | Annual preventive visit | completed | |
appointment | Annual preventive visit | completed |
Lab panel: HbA1c 6.0%, LDL 3.0 mmol/L, eGFR 51, ACR 8.5. Interpret in clinical context.
125 mmHg
2026-02-14Diastolic Bp
69 mmHg
2026-02-14Bmi
31.3 kg/m2
2026-02-14Smoking Status
never
2026-02-14Hba1c
5.1 %
2025-01-13Fasting Glucose
6 mmol/L
2025-01-13Ldl Cholesterol
3.3 mmol/L
2025-01-13Egfr
54 mL/min/1.73m2
2025-01-13Albumin Creatinine Ratio
8.8 mg/mmol
2025-01-13Systolic Bp
124 mmHg
2025-01-13Diastolic Bp
68 mmHg
2025-01-13Bmi
30.3 kg/m2
2025-01-13Smoking Status
never
2025-01-13Hba1c
6.2 %
2024-12-12Fasting Glucose
5.9 mmol/L
2024-12-12Ldl Cholesterol
3.2 mmol/L
2024-12-12Egfr
53 mL/min/1.73m2
2024-12-12Albumin Creatinine Ratio
8.7 mg/mmol
2024-12-12Systolic Bp
123 mmHg
2024-12-12Diastolic Bp
80 mmHg
2024-12-12Bmi
29.3 kg/m2
2024-12-12Smoking Status
never
2024-12-12Hba1c
6.1 %
2023-11-11Fasting Glucose
5.8 mmol/L
2023-11-11Ldl Cholesterol
3.1 mmol/L
2023-11-11Egfr
52 mL/min/1.73m2
2023-11-11Albumin Creatinine Ratio
8.6 mg/mmol
2023-11-11Systolic Bp
122 mmHg
2023-11-11Diastolic Bp
79 mmHg
2023-11-11Bmi
28.3 kg/m2
2023-11-11Smoking Status
never
2023-11-11Hba1c
6 %
2022-10-10Fasting Glucose
5.7 mmol/L
2022-10-10Ldl Cholesterol
3 mmol/L
2022-10-10Egfr
51 mL/min/1.73m2
2022-10-10Albumin Creatinine Ratio
8.5 mg/mmol
2022-10-10Systolic Bp
121 mmHg
2022-10-10Diastolic Bp
78 mmHg
2022-10-10Bmi
27.3 kg/m2
2022-10-10Smoking Status
never
2022-10-10Hba1c
5.9 %
2021-09-09Fasting Glucose
5.6 mmol/L
2021-09-09Ldl Cholesterol
2.9 mmol/L
2021-09-09Egfr
50 mL/min/1.73m2
2021-09-09Albumin Creatinine Ratio
8.4 mg/mmol
2021-09-09Systolic Bp
120 mmHg
2021-09-09Diastolic Bp
77 mmHg
2021-09-09Bmi
26.3 kg/m2
2021-09-09Smoking Status
never
2021-09-09Hba1c
5.8 %
2020-08-08Fasting Glucose
5.5 mmol/L
2020-08-08Ldl Cholesterol
2.8 mmol/L
2020-08-08Egfr
49 mL/min/1.73m2
2020-08-08Albumin Creatinine Ratio
8.3 mg/mmol
2020-08-08Systolic Bp
119 mmHg
2020-08-08Diastolic Bp
76 mmHg
2020-08-08Bmi
25.3 kg/m2
2020-08-08Smoking Status
never
2020-08-08