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1, current
Smoking / Lung Screening review cohort
Chart evidence: Care element: smoking_status never synthetic-demo | Clinical note: SOAP note Diabetes follow-up S: Patient seen for longitudinal primary care follow-up. Reports va...
membership needs review
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1
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Last visit
2026-01-22
Appointment or derived chart contact
Latest A1c
8.3 %
2026-06-18
Latest BP
129 mmHg / 73 mmHg
2026-06-18
Extracted signals
0
Optional text signals
Chart volume
92
7 notes, 7 reports
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Review priority
3
active signal
s
1
11
0
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Review needed
1 open flag
Open clinical review items need status, assignment, or closure.
A1c above review threshold
Latest HbA1c is 8.3 % on 2026-06-18.
Future-dated imported records
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Active problems
3
Type 2 diabetes mellitus
E11
active
Dyslipidemia
E78.5
active
Asthma
J45
active
Active medications
3
Metformin
500mg BID
Rosuvastatin
10mg daily
Salbutamol inhaler
100mcg PRN
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0, selected
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78, more source rows below
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11
imported record
s
appear future-dated relative to today. Keep them visible for audit, but review source dates before using them clinically.
note
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 137/89, BMI 26.7, cardiopulmonary exam stable, feet checked when diab
report
Laboratory
Lab panel: HbA1c 8.3%, LDL 3.8 mmol/L, eGFR 86, ACR 0.8. Interpret in clinical context.
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status never synthetic-demo | Clinical note: SOAP note Diabetes follow-up S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 137/89, BMI 26.7,... | Clinical note: SOAP note Diabetes follow-up S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 136/88, BMI 25.7,... | Care element: smoking_status never synthetic-demo | probable
clinical_flag
Synthetic diabetes monitoring review
new | medium | synthetic_longitudinal_data | Longitudinal synthetic data suggests diabetes with recent monitoring possibly due.
appointment
Chronic disease follow-up
cancelled
appointment
Chronic disease follow-up
completed
note
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 136/88, BMI 25.7, cardiopulmonary exam stable, feet checked when diab
report
Laboratory
Lab panel: HbA1c 8.2%, LDL 3.7 mmol/L, eGFR 85, ACR 0.7. Interpret in clinical context.
appointment
Chronic disease follow-up
completed
appointment
Chronic disease follow-up
completed
note
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 135/87, BMI 24.7, cardiopulmonary exam stable, feet checked when diab
report
Laboratory
Lab panel: HbA1c 8.1%, LDL 3.6 mmol/L, eGFR 84, ACR 2.2. Interpret in clinical context.
appointment
Chronic disease follow-up
completed
appointment
Chronic disease follow-up
completed
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 137/89, BMI 26.7, cardiopulmonary exam stable, feet checked when diabetes present. A: Type 2 diabetes follow-up; 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 variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 136/88, BMI 25.7, cardiopulmonary exam stable, feet checked when diabetes present. A: Type 2 diabetes follow-up; 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 variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 135/87, BMI 24.7, cardiopulmonary exam stable, feet checked when diabetes present. A: Type 2 diabetes follow-up; 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 variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 134/86, BMI 23.7, cardiopulmonary exam stable, feet checked when diabetes present. A: Type 2 diabetes follow-up; 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 diabetes monitoring review
Longitudinal synthetic data suggests diabetes with recent monitoring possibly due.
Laboratory
Lab panel: HbA1c 8.3%, LDL 3.8 mmol/L, eGFR 86, ACR 0.8. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 8.2%, LDL 3.7 mmol/L, eGFR 85, ACR 0.7. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 8.1%, LDL 3.6 mmol/L, eGFR 84, ACR 2.2. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 8.0%, LDL 3.5 mmol/L, eGFR 83, ACR 2.1. Interpret in clinical context.
Laboratory
Hba1c
8.3 %
2026-06-18Fasting Glucose
9.1 mmol/L
2026-06-18Ldl Cholesterol
3.8 mmol/L
2026-06-18Egfr
86 mL/min/1.73m2
2026-06-18Albumin Creatinine Ratio
0.8 mg/mmol
2026-06-18Systolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 137/89, BMI 26.7, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 8.3%, LDL 3.8 mmol/L, eGFR 86, ACR 0.8. Interpret in clinical context. | |
care_element | bmi | 22.0 | |
care_element | hba1c | 8.3 | |
care_element | fasting_glucose | 9.1 | |
care_element | systolic_bp | 129 | |
care_element | smoking_status | never | |
care_element | ldl_cholesterol | 3.8 | |
care_element | egfr | 86 | |
care_element | diastolic_bp | 73 | |
care_element | albumin_creatinine_ratio | 0.8 | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status never synthetic-demo | Clinical note: SOAP note Diabetes follow-up S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 137/89, BMI 26.7,... | Clinical note: SOAP note Diabetes follow-up S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 136/88, BMI 25.7,... | Care element: smoking_status never synthetic-demo | probable | |
clinical_flag | Synthetic diabetes monitoring review | new | medium | synthetic_longitudinal_data | Longitudinal synthetic data suggests diabetes with recent monitoring possibly due. | |
appointment | Chronic disease follow-up | cancelled | |
appointment | Chronic disease follow-up | completed | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 136/88, BMI 25.7, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 8.2%, LDL 3.7 mmol/L, eGFR 85, ACR 0.7. Interpret in clinical context. | |
care_element | systolic_bp | 128 | |
care_element | smoking_status | never | |
care_element | bmi | 38.0 | |
care_element | diastolic_bp | 72 | |
care_element | albumin_creatinine_ratio | 0.7 | |
care_element | egfr | 85 | |
care_element | ldl_cholesterol | 3.7 | |
care_element | fasting_glucose | 9.0 | |
care_element | hba1c | 8.2 | |
appointment | Chronic disease follow-up | completed | |
appointment | Chronic disease follow-up | completed | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 135/87, BMI 24.7, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 8.1%, LDL 3.6 mmol/L, eGFR 84, ACR 2.2. Interpret in clinical context. | |
care_element | systolic_bp | 127 | |
care_element | albumin_creatinine_ratio | 2.2 | |
care_element | egfr | 84 | |
care_element | smoking_status | never | |
care_element | bmi | 37.0 | |
care_element | ldl_cholesterol | 3.6 | |
care_element | hba1c | 8.1 | |
care_element | fasting_glucose | 8.9 | |
care_element | diastolic_bp | 71 | |
appointment | Chronic disease follow-up | completed | |
appointment | Chronic disease follow-up | completed | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 134/86, BMI 23.7, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 8.0%, LDL 3.5 mmol/L, eGFR 83, ACR 2.1. Interpret in clinical context. | |
care_element | hba1c | 8.0 | |
care_element | egfr | 83 | |
care_element | ldl_cholesterol | 3.5 | |
care_element | fasting_glucose | 8.8 | |
care_element | smoking_status | never | |
care_element | bmi | 36.0 | |
care_element | diastolic_bp | 70 | |
care_element | systolic_bp | 126 | |
care_element | albumin_creatinine_ratio | 2.1 | |
appointment | Chronic disease follow-up | completed | |
appointment | Chronic disease follow-up | completed | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 133/85, BMI 36.7, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 7.9%, LDL 3.4 mmol/L, eGFR 82, ACR 2.0. Interpret in clinical context. | |
care_element | fasting_glucose | 8.7 | |
care_element | hba1c | 7.9 | |
care_element | smoking_status | never | |
care_element | bmi | 35.0 | |
care_element | diastolic_bp | 69 | |
care_element | systolic_bp | 125 | |
care_element | albumin_creatinine_ratio | 2.0 | |
care_element | egfr | 82 | |
care_element | ldl_cholesterol | 3.4 | |
appointment | Chronic disease follow-up | completed | |
appointment | Chronic disease follow-up | completed | |
appointment | Chronic disease follow-up | completed | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 132/84, BMI 35.7, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 7.8%, LDL 3.3 mmol/L, eGFR 81, ACR 1.9. Interpret in clinical context. | |
care_element | egfr | 81 | |
care_element | ldl_cholesterol | 3.3 | |
care_element | fasting_glucose | 8.6 | |
care_element | smoking_status | never | |
care_element | hba1c | 7.8 | |
care_element | bmi | 34.0 | |
care_element | diastolic_bp | 68 | |
care_element | systolic_bp | 124 | |
care_element | albumin_creatinine_ratio | 1.9 | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 131/83, BMI 34.7, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 7.7%, LDL 3.2 mmol/L, eGFR 80, ACR 1.8. Interpret in clinical context. | |
care_element | smoking_status | never | |
care_element | bmi | 33.0 | |
care_element | diastolic_bp | 80 | |
care_element | systolic_bp | 123 | |
care_element | albumin_creatinine_ratio | 1.8 | |
care_element | egfr | 80 | |
care_element | ldl_cholesterol | 3.2 | |
care_element | fasting_glucose | 8.5 | |
care_element | hba1c | 7.7 | |
appointment | Chronic disease follow-up | completed | |
appointment | Chronic disease follow-up | completed |
Lab panel: HbA1c 7.9%, LDL 3.4 mmol/L, eGFR 82, ACR 2.0. Interpret in clinical context.
129 mmHg
2026-06-18Diastolic Bp
73 mmHg
2026-06-18Bmi
22 kg/m2
2026-06-18Smoking Status
never
2026-06-18Hba1c
8.2 %
2025-05-17Fasting Glucose
9 mmol/L
2025-05-17Ldl Cholesterol
3.7 mmol/L
2025-05-17Egfr
85 mL/min/1.73m2
2025-05-17Albumin Creatinine Ratio
0.7 mg/mmol
2025-05-17Systolic Bp
128 mmHg
2025-05-17Diastolic Bp
72 mmHg
2025-05-17Bmi
38 kg/m2
2025-05-17Smoking Status
never
2025-05-17Hba1c
8.1 %
2024-04-16Fasting Glucose
8.9 mmol/L
2024-04-16Ldl Cholesterol
3.6 mmol/L
2024-04-16Egfr
84 mL/min/1.73m2
2024-04-16Albumin Creatinine Ratio
2.2 mg/mmol
2024-04-16Systolic Bp
127 mmHg
2024-04-16Diastolic Bp
71 mmHg
2024-04-16Bmi
37 kg/m2
2024-04-16Smoking Status
never
2024-04-16Hba1c
8 %
2023-03-15Fasting Glucose
8.8 mmol/L
2023-03-15Ldl Cholesterol
3.5 mmol/L
2023-03-15Egfr
83 mL/min/1.73m2
2023-03-15Albumin Creatinine Ratio
2.1 mg/mmol
2023-03-15Systolic Bp
126 mmHg
2023-03-15Diastolic Bp
70 mmHg
2023-03-15Bmi
36 kg/m2
2023-03-15Smoking Status
never
2023-03-15Hba1c
7.9 %
2022-02-14Fasting Glucose
8.7 mmol/L
2022-02-14Ldl Cholesterol
3.4 mmol/L
2022-02-14Egfr
82 mL/min/1.73m2
2022-02-14Albumin Creatinine Ratio
2 mg/mmol
2022-02-14Systolic Bp
125 mmHg
2022-02-14Diastolic Bp
69 mmHg
2022-02-14Bmi
35 kg/m2
2022-02-14Smoking Status
never
2022-02-14Hba1c
7.8 %
2021-01-13Fasting Glucose
8.6 mmol/L
2021-01-13Ldl Cholesterol
3.3 mmol/L
2021-01-13Egfr
81 mL/min/1.73m2
2021-01-13Albumin Creatinine Ratio
1.9 mg/mmol
2021-01-13Systolic Bp
124 mmHg
2021-01-13Diastolic Bp
68 mmHg
2021-01-13Bmi
34 kg/m2
2021-01-13Smoking Status
never
2021-01-13Hba1c
7.7 %
2020-12-12Fasting Glucose
8.5 mmol/L
2020-12-12Ldl Cholesterol
3.2 mmol/L
2020-12-12Egfr
80 mL/min/1.73m2
2020-12-12Albumin Creatinine Ratio
1.8 mg/mmol
2020-12-12Systolic Bp
123 mmHg
2020-12-12Diastolic Bp
80 mmHg
2020-12-12Bmi
33 kg/m2
2020-12-12Smoking Status
never
2020-12-12