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1, current
Smoking / Lung Screening review cohort
Chart evidence: Care element: smoking_status never synthetic-demo | Clinical note: SOAP note Hypertension follow-up S: Patient seen for longitudinal primary care follow-up. Report...
membership needs review
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Open review tasks
1
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Last visit
2026-01-23
Appointment or derived chart contact
Latest A1c
5.7 %
2026-07-19
Latest BP
138 mmHg / 86 mmHg
2026-07-19
Extracted signals
0
Optional text signals
Chart volume
93
7 notes, 7 reports
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Review priority
2
active signal
s
1
11
0
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1 open flag
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Future-dated imported records
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Active problems
2
Essential hypertension
I10
active
Dyslipidemia
E78.5
active
Active medications
3
Metformin
500mg BID
Ramipril
5mg daily
Rosuvastatin
10mg daily
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0, selected
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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 general preventive care concerns, with home BP readings sometimes above target. O: BP 138/72, BMI 29.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.7%, LDL 3.9 mmol/L, eGFR 87, ACR 0.9. 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 Hypertension follow-up S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with home BP readings sometimes above target. O: BP 138/72, BMI 29.8, cardiopulmonary... | Clinical note: SOAP note Hypertension follow-up S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with home BP readings sometimes above target. O: BP 137/89, BMI 28.8, cardiopulmonary... | Care element: smoking_status never synthetic-demo | probable
clinical_flag
Synthetic BP follow-up review
new | medium | synthetic_longitudinal_data | Several synthetic BP readings are above target and need clinician review.
alert
Preventive care review due
Synthetic alert for testing active cohort and review workflows.
appointment
Annual preventive visit
completed
appointment
Annual preventive visit
cancelled
note
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with home BP readings sometimes above target. O: BP 137/89, BMI 28.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.6%, LDL 3.8 mmol/L, eGFR 86, ACR 0.8. 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 home BP readings sometimes above target. O: BP 136/88, BMI 27.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.5%, LDL 3.7 mmol/L, eGFR 85, ACR 0.7. Interpret in clinical context.
appointment
Annual preventive visit
completed
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with home BP readings sometimes above target. O: BP 138/72, BMI 29.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care review; hypertension monitoring; 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 home BP readings sometimes above target. O: BP 137/89, BMI 28.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care review; hypertension monitoring; 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 home BP readings sometimes above target. O: BP 136/88, BMI 27.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care review; hypertension monitoring; 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 home BP readings sometimes above target. O: BP 135/87, BMI 26.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care review; hypertension monitoring; 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 BP follow-up review
Several synthetic BP readings are above target and need clinician review.
Laboratory
Lab panel: HbA1c 5.7%, LDL 3.9 mmol/L, eGFR 87, ACR 0.9. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 5.6%, LDL 3.8 mmol/L, eGFR 86, ACR 0.8. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 5.5%, LDL 3.7 mmol/L, eGFR 85, ACR 0.7. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 5.4%, LDL 3.6 mmol/L, eGFR 84, ACR 2.2. Interpret in clinical context.
Laboratory
Hba1c
5.7 %
2026-07-19Fasting Glucose
5 mmol/L
2026-07-19Ldl Cholesterol
3.9 mmol/L
2026-07-19Egfr
87 mL/min/1.73m2
2026-07-19Albumin Creatinine Ratio
0.9 mg/mmol
2026-07-19Systolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with home BP readings sometimes above target. O: BP 138/72, BMI 29.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.7%, LDL 3.9 mmol/L, eGFR 87, ACR 0.9. Interpret in clinical context. | |
care_element | fasting_glucose | 5.0 | |
care_element | bmi | 24.1 | |
care_element | hba1c | 5.7 | |
care_element | ldl_cholesterol | 3.9 | |
care_element | egfr | 87 | |
care_element | diastolic_bp | 86 | |
care_element | smoking_status | never | |
care_element | albumin_creatinine_ratio | 0.9 | |
care_element | systolic_bp | 138 | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status never synthetic-demo | Clinical note: SOAP note Hypertension follow-up S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with home BP readings sometimes above target. O: BP 138/72, BMI 29.8, cardiopulmonary... | Clinical note: SOAP note Hypertension follow-up S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with home BP readings sometimes above target. O: BP 137/89, BMI 28.8, cardiopulmonary... | Care element: smoking_status never synthetic-demo | probable | |
clinical_flag | Synthetic BP follow-up review | new | medium | synthetic_longitudinal_data | Several synthetic BP readings are above target and need clinician review. | |
alert | Preventive care review due | Synthetic alert for testing active cohort and review workflows. | |
appointment | Annual preventive visit | completed | |
appointment | Annual preventive visit | cancelled | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with home BP readings sometimes above target. O: BP 137/89, BMI 28.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.6%, LDL 3.8 mmol/L, eGFR 86, ACR 0.8. Interpret in clinical context. | |
care_element | ldl_cholesterol | 3.8 | |
care_element | albumin_creatinine_ratio | 0.8 | |
care_element | egfr | 86 | |
care_element | fasting_glucose | 4.9 | |
care_element | systolic_bp | 137 | |
care_element | diastolic_bp | 85 | |
care_element | hba1c | 5.6 | |
care_element | smoking_status | never | |
care_element | bmi | 23.1 | |
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 home BP readings sometimes above target. O: BP 136/88, BMI 27.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.5%, LDL 3.7 mmol/L, eGFR 85, ACR 0.7. Interpret in clinical context. | |
care_element | smoking_status | never | |
care_element | systolic_bp | 136 | |
care_element | albumin_creatinine_ratio | 0.7 | |
care_element | ldl_cholesterol | 3.7 | |
care_element | bmi | 22.1 | |
care_element | hba1c | 5.5 | |
care_element | diastolic_bp | 84 | |
care_element | fasting_glucose | 4.8 | |
care_element | egfr | 85 | |
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 home BP readings sometimes above target. O: BP 135/87, BMI 26.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.4%, LDL 3.6 mmol/L, eGFR 84, ACR 2.2. Interpret in clinical context. | |
care_element | fasting_glucose | 6.3 | |
care_element | diastolic_bp | 83 | |
care_element | egfr | 84 | |
care_element | smoking_status | never | |
care_element | bmi | 38.1 | |
care_element | hba1c | 5.4 | |
care_element | systolic_bp | 135 | |
care_element | albumin_creatinine_ratio | 2.2 | |
care_element | ldl_cholesterol | 3.6 | |
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 home BP readings sometimes above target. O: BP 134/86, BMI 25.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.3%, LDL 3.5 mmol/L, eGFR 83, ACR 2.1. Interpret in clinical context. | |
care_element | diastolic_bp | 82 | |
care_element | fasting_glucose | 6.2 | |
care_element | systolic_bp | 134 | |
care_element | egfr | 83 | |
care_element | smoking_status | never | |
care_element | albumin_creatinine_ratio | 2.1 | |
care_element | ldl_cholesterol | 3.5 | |
care_element | bmi | 37.1 | |
care_element | hba1c | 5.3 | |
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 home BP readings sometimes above target. O: BP 133/85, BMI 24.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.2%, LDL 3.4 mmol/L, eGFR 82, ACR 2.0. Interpret in clinical context. | |
care_element | bmi | 36.1 | |
care_element | diastolic_bp | 95 | |
care_element | hba1c | 5.2 | |
care_element | ldl_cholesterol | 3.4 | |
care_element | albumin_creatinine_ratio | 2.0 | |
care_element | smoking_status | never | |
care_element | egfr | 82 | |
care_element | systolic_bp | 133 | |
care_element | fasting_glucose | 6.1 | |
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 home BP readings sometimes above target. O: BP 132/84, BMI 23.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.1%, LDL 3.3 mmol/L, eGFR 81, ACR 1.9. Interpret in clinical context. | |
care_element | diastolic_bp | 94 | |
care_element | fasting_glucose | 6.0 | |
care_element | bmi | 35.1 | |
care_element | egfr | 81 | |
care_element | smoking_status | never | |
care_element | hba1c | 5.1 | |
care_element | albumin_creatinine_ratio | 1.9 | |
care_element | ldl_cholesterol | 3.3 | |
care_element | systolic_bp | 132 |
Lab panel: HbA1c 5.3%, LDL 3.5 mmol/L, eGFR 83, ACR 2.1. Interpret in clinical context.
138 mmHg
2026-07-19Diastolic Bp
86 mmHg
2026-07-19Bmi
24.1 kg/m2
2026-07-19Smoking Status
never
2026-07-19Hba1c
5.6 %
2025-06-18Fasting Glucose
4.9 mmol/L
2025-06-18Ldl Cholesterol
3.8 mmol/L
2025-06-18Egfr
86 mL/min/1.73m2
2025-06-18Albumin Creatinine Ratio
0.8 mg/mmol
2025-06-18Systolic Bp
137 mmHg
2025-06-18Diastolic Bp
85 mmHg
2025-06-18Bmi
23.1 kg/m2
2025-06-18Smoking Status
never
2025-06-18Hba1c
5.5 %
2024-05-17Fasting Glucose
4.8 mmol/L
2024-05-17Ldl Cholesterol
3.7 mmol/L
2024-05-17Egfr
85 mL/min/1.73m2
2024-05-17Albumin Creatinine Ratio
0.7 mg/mmol
2024-05-17Systolic Bp
136 mmHg
2024-05-17Diastolic Bp
84 mmHg
2024-05-17Bmi
22.1 kg/m2
2024-05-17Smoking Status
never
2024-05-17Hba1c
5.4 %
2023-04-16Fasting Glucose
6.3 mmol/L
2023-04-16Ldl Cholesterol
3.6 mmol/L
2023-04-16Egfr
84 mL/min/1.73m2
2023-04-16Albumin Creatinine Ratio
2.2 mg/mmol
2023-04-16Systolic Bp
135 mmHg
2023-04-16Diastolic Bp
83 mmHg
2023-04-16Bmi
38.1 kg/m2
2023-04-16Smoking Status
never
2023-04-16Hba1c
5.3 %
2022-03-15Fasting Glucose
6.2 mmol/L
2022-03-15Ldl Cholesterol
3.5 mmol/L
2022-03-15Egfr
83 mL/min/1.73m2
2022-03-15Albumin Creatinine Ratio
2.1 mg/mmol
2022-03-15Systolic Bp
134 mmHg
2022-03-15Diastolic Bp
82 mmHg
2022-03-15Bmi
37.1 kg/m2
2022-03-15Smoking Status
never
2022-03-15Hba1c
5.2 %
2021-02-14Fasting Glucose
6.1 mmol/L
2021-02-14Ldl Cholesterol
3.4 mmol/L
2021-02-14Egfr
82 mL/min/1.73m2
2021-02-14Albumin Creatinine Ratio
2 mg/mmol
2021-02-14Systolic Bp
133 mmHg
2021-02-14Diastolic Bp
95 mmHg
2021-02-14Bmi
36.1 kg/m2
2021-02-14Smoking Status
never
2021-02-14Hba1c
5.1 %
2020-01-13Fasting Glucose
6 mmol/L
2020-01-13Ldl Cholesterol
3.3 mmol/L
2020-01-13Egfr
81 mL/min/1.73m2
2020-01-13Albumin Creatinine Ratio
1.9 mg/mmol
2020-01-13Systolic Bp
132 mmHg
2020-01-13Diastolic Bp
94 mmHg
2020-01-13Bmi
35.1 kg/m2
2020-01-13Smoking Status
never
2020-01-13