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Population Health
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2, current
Mental Health review cohort
Chart evidence: Clinical note: SOAP note Hypertension follow-up S: Patient seen for longitudinal primary care follow-up. Reports general preventive care concerns, with home BP rea...
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 never synthetic-demo | Clinical note: SOAP note Hypertension follow-up S: Patient seen for longitudinal primary care follow-up. Report...
Open review tasks
1
New, in review, or accepted tasks
Last visit
2026-01-24
Appointment or derived chart contact
Latest A1c
5.8 %
2026-08-20
Latest BP
139 mmHg / 87 mmHg
2026-08-20
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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Review needed
1 open flag
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Future-dated imported records
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Active problems
2
Essential hypertension
I10
active
Depressive disorder
F32.9
active
Active medications
2
Ramipril
5mg daily
Sertraline
50mg daily
membership needs review
No review task has been created from this cohort for this patient yet.
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0, selected
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79, 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 general preventive care concerns, with home BP readings sometimes above target. O: BP 139/73, BMI 32.9, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.8%, LDL 4.0 mmol/L, eGFR 88, ACR 1.0. Interpret in clinical context.
cohort_run
Cohort: Mental Health review cohort
completed | Chart evidence: 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 139/73, BMI 32.9, 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 138/72, BMI 31.9, 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 30.9, 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 136/88, BMI 29.9, cardiopulmonary... | probable
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 139/73, BMI 32.9, 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 138/72, BMI 31.9, 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.
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 138/72, BMI 31.9, 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.
appointment
Annual preventive visit
cancelled
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 137/89, BMI 30.9, 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
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 139/73, BMI 32.9, 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 138/72, BMI 31.9, 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 30.9, 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 29.9, 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 5.8%, LDL 4.0 mmol/L, eGFR 88, ACR 1.0. Interpret in clinical context.
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
Hba1c
5.8 %
2026-08-20Fasting Glucose
5.1 mmol/L
2026-08-20Ldl Cholesterol
4 mmol/L
2026-08-20Egfr
88 mL/min/1.73m2
2026-08-20Albumin Creatinine Ratio
1 mg/mmol
2026-08-20Systolic 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 139/73, BMI 32.9, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.8%, LDL 4.0 mmol/L, eGFR 88, ACR 1.0. Interpret in clinical context. | |
care_element | albumin_creatinine_ratio | 1.0 | |
care_element | ldl_cholesterol | 4.0 | |
care_element | egfr | 88 | |
care_element | bmi | 26.2 | |
care_element | diastolic_bp | 87 | |
care_element | systolic_bp | 139 | |
care_element | smoking_status | never | |
care_element | hba1c | 5.8 | |
care_element | fasting_glucose | 5.1 | |
cohort_run | Cohort: Mental Health review cohort | completed | Chart evidence: 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 139/73, BMI 32.9, 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 138/72, BMI 31.9, 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 30.9, 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 136/88, BMI 29.9, cardiopulmonary... | probable | |
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 139/73, BMI 32.9, 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 138/72, BMI 31.9, 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. | |
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 138/72, BMI 31.9, 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 | smoking_status | never | |
care_element | bmi | 25.2 | |
care_element | diastolic_bp | 86 | |
care_element | systolic_bp | 138 | |
care_element | albumin_creatinine_ratio | 0.9 | |
care_element | egfr | 87 | |
care_element | ldl_cholesterol | 3.9 | |
care_element | fasting_glucose | 5.0 | |
care_element | hba1c | 5.7 | |
appointment | Annual preventive visit | cancelled | |
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 137/89, BMI 30.9, 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 | smoking_status | never | |
care_element | bmi | 24.2 | |
care_element | albumin_creatinine_ratio | 0.8 | |
care_element | egfr | 86 | |
care_element | systolic_bp | 137 | |
care_element | ldl_cholesterol | 3.8 | |
care_element | fasting_glucose | 4.9 | |
care_element | hba1c | 5.6 | |
care_element | diastolic_bp | 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 136/88, BMI 29.9, 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 | fasting_glucose | 4.8 | |
care_element | ldl_cholesterol | 3.7 | |
care_element | albumin_creatinine_ratio | 0.7 | |
care_element | egfr | 85 | |
care_element | hba1c | 5.5 | |
care_element | smoking_status | never | |
care_element | bmi | 23.2 | |
care_element | diastolic_bp | 84 | |
care_element | systolic_bp | 136 | |
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 28.9, 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 | smoking_status | never | |
care_element | bmi | 22.2 | |
care_element | diastolic_bp | 83 | |
care_element | systolic_bp | 135 | |
care_element | albumin_creatinine_ratio | 2.2 | |
care_element | egfr | 84 | |
care_element | ldl_cholesterol | 3.6 | |
care_element | fasting_glucose | 6.3 | |
care_element | hba1c | 5.4 | |
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 27.9, 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 | smoking_status | never | |
care_element | egfr | 83 | |
care_element | ldl_cholesterol | 3.5 | |
care_element | fasting_glucose | 6.2 | |
care_element | hba1c | 5.3 | |
care_element | systolic_bp | 134 | |
care_element | albumin_creatinine_ratio | 2.1 | |
care_element | diastolic_bp | 82 | |
care_element | bmi | 38.2 | |
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 home BP readings sometimes above target. O: BP 133/85, BMI 26.9, 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 | hba1c | 5.2 | |
care_element | egfr | 82 | |
care_element | albumin_creatinine_ratio | 2.0 | |
care_element | smoking_status | never | |
care_element | fasting_glucose | 6.1 | |
care_element | ldl_cholesterol | 3.4 | |
care_element | systolic_bp | 133 | |
care_element | diastolic_bp | 95 | |
care_element | bmi | 37.2 | |
appointment | Annual preventive visit | completed |
Lab panel: HbA1c 5.4%, LDL 3.6 mmol/L, eGFR 84, ACR 2.2. Interpret in clinical context.
139 mmHg
2026-08-20Diastolic Bp
87 mmHg
2026-08-20Bmi
26.2 kg/m2
2026-08-20Smoking Status
never
2026-08-20Hba1c
5.7 %
2025-07-19Fasting Glucose
5 mmol/L
2025-07-19Ldl Cholesterol
3.9 mmol/L
2025-07-19Egfr
87 mL/min/1.73m2
2025-07-19Albumin Creatinine Ratio
0.9 mg/mmol
2025-07-19Systolic Bp
138 mmHg
2025-07-19Diastolic Bp
86 mmHg
2025-07-19Bmi
25.2 kg/m2
2025-07-19Smoking Status
never
2025-07-19Hba1c
5.6 %
2024-06-18Fasting Glucose
4.9 mmol/L
2024-06-18Ldl Cholesterol
3.8 mmol/L
2024-06-18Egfr
86 mL/min/1.73m2
2024-06-18Albumin Creatinine Ratio
0.8 mg/mmol
2024-06-18Systolic Bp
137 mmHg
2024-06-18Diastolic Bp
85 mmHg
2024-06-18Bmi
24.2 kg/m2
2024-06-18Smoking Status
never
2024-06-18Hba1c
5.5 %
2023-05-17Fasting Glucose
4.8 mmol/L
2023-05-17Ldl Cholesterol
3.7 mmol/L
2023-05-17Egfr
85 mL/min/1.73m2
2023-05-17Albumin Creatinine Ratio
0.7 mg/mmol
2023-05-17Systolic Bp
136 mmHg
2023-05-17Diastolic Bp
84 mmHg
2023-05-17Bmi
23.2 kg/m2
2023-05-17Smoking Status
never
2023-05-17Hba1c
5.4 %
2022-04-16Fasting Glucose
6.3 mmol/L
2022-04-16Ldl Cholesterol
3.6 mmol/L
2022-04-16Egfr
84 mL/min/1.73m2
2022-04-16Albumin Creatinine Ratio
2.2 mg/mmol
2022-04-16Systolic Bp
135 mmHg
2022-04-16Diastolic Bp
83 mmHg
2022-04-16Bmi
22.2 kg/m2
2022-04-16Smoking Status
never
2022-04-16Hba1c
5.3 %
2021-03-15Fasting Glucose
6.2 mmol/L
2021-03-15Ldl Cholesterol
3.5 mmol/L
2021-03-15Egfr
83 mL/min/1.73m2
2021-03-15Albumin Creatinine Ratio
2.1 mg/mmol
2021-03-15Systolic Bp
134 mmHg
2021-03-15Diastolic Bp
82 mmHg
2021-03-15Bmi
38.2 kg/m2
2021-03-15Smoking Status
never
2021-03-15Hba1c
5.2 %
2020-02-14Fasting Glucose
6.1 mmol/L
2020-02-14Ldl Cholesterol
3.4 mmol/L
2020-02-14Egfr
82 mL/min/1.73m2
2020-02-14Albumin Creatinine Ratio
2 mg/mmol
2020-02-14Systolic Bp
133 mmHg
2020-02-14Diastolic Bp
95 mmHg
2020-02-14Bmi
37.2 kg/m2
2020-02-14Smoking Status
never
2020-02-14