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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
2026-01-20
Appointment or derived chart contact
Latest A1c
5.3 %
2026-03-15
Latest BP
132 mmHg / 92 mmHg
2026-03-15
Extracted signals
0
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Chart volume
93
7 notes, 7 reports
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Review priority
2
active signal
s
1
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1 open flag
Open clinical review items need status, assignment, or closure.
BP above target
Latest BP is 132 mmHg / 92 mmHg on 2026-03-15.
Active problems
3
Essential hypertension
I10
active
Dyslipidemia
E78.5
active
Asthma
J45
active
Active medications
4
Metformin
500mg BID
Ramipril
5mg daily
Rosuvastatin
10mg daily
Salbutamol inhaler
100mcg PRN
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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 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 120/74, BMI 33.8, 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 119/73, BMI 32.8, cardiopulmonary... | Care element: smoking_status never synthetic-demo | probable
alert
Preventive care review due
Synthetic alert for testing active cohort and review workflows.
clinical_flag
Synthetic BP follow-up review
new | medium | synthetic_longitudinal_data | Several synthetic BP readings are above target and need clinician review.
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 120/74, BMI 33.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.3%, LDL 2.9 mmol/L, eGFR 76, ACR 1.3. 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 119/73, BMI 32.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.2%, LDL 2.8 mmol/L, eGFR 75, ACR 1.2. Interpret in clinical context.
appointment
Annual preventive visit
cancelled
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 118/72, BMI 31.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.1%, LDL 2.7 mmol/L, eGFR 74, ACR 1.1. Interpret in clinical context.
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 120/74, BMI 33.8, 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 119/73, BMI 32.8, 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 118/72, BMI 31.8, 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 155/89, BMI 30.8, 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 5.3%, LDL 2.9 mmol/L, eGFR 76, ACR 1.3. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 5.2%, LDL 2.8 mmol/L, eGFR 75, ACR 1.2. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 5.1%, LDL 2.7 mmol/L, eGFR 74, ACR 1.1. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 6.2%, LDL 2.6 mmol/L, eGFR 73, ACR 1.0. Interpret in clinical context.
Laboratory
Hba1c
5.3 %
2026-03-15Fasting Glucose
5.4 mmol/L
2026-03-15Ldl Cholesterol
2.9 mmol/L
2026-03-15Egfr
76 mL/min/1.73m2
2026-03-15Albumin Creatinine Ratio
1.3 mg/mmol
2026-03-15Systolic 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 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 120/74, BMI 33.8, 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 119/73, BMI 32.8, cardiopulmonary... | Care element: smoking_status never synthetic-demo | probable | |
alert | Preventive care review due | Synthetic alert for testing active cohort and review workflows. | |
clinical_flag | Synthetic BP follow-up review | new | medium | synthetic_longitudinal_data | Several synthetic BP readings are above target and need clinician review. | |
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 120/74, BMI 33.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.3%, LDL 2.9 mmol/L, eGFR 76, ACR 1.3. Interpret in clinical context. | |
care_element | bmi | 30.0 | |
care_element | hba1c | 5.3 | |
care_element | systolic_bp | 132 | |
care_element | diastolic_bp | 92 | |
care_element | fasting_glucose | 5.4 | |
care_element | smoking_status | never | |
care_element | egfr | 76 | |
care_element | albumin_creatinine_ratio | 1.3 | |
care_element | ldl_cholesterol | 2.9 | |
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 119/73, BMI 32.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.2%, LDL 2.8 mmol/L, eGFR 75, ACR 1.2. Interpret in clinical context. | |
care_element | egfr | 75 | |
care_element | systolic_bp | 157 | |
care_element | smoking_status | never | |
care_element | ldl_cholesterol | 2.8 | |
care_element | albumin_creatinine_ratio | 1.2 | |
care_element | hba1c | 5.2 | |
care_element | bmi | 29.0 | |
care_element | diastolic_bp | 91 | |
care_element | fasting_glucose | 5.3 | |
appointment | Annual preventive visit | cancelled | |
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 118/72, BMI 31.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.1%, LDL 2.7 mmol/L, eGFR 74, ACR 1.1. Interpret in clinical context. | |
care_element | bmi | 28.0 | |
care_element | ldl_cholesterol | 2.7 | |
care_element | albumin_creatinine_ratio | 1.1 | |
care_element | fasting_glucose | 5.2 | |
care_element | systolic_bp | 156 | |
care_element | hba1c | 5.1 | |
care_element | diastolic_bp | 90 | |
care_element | egfr | 74 | |
care_element | smoking_status | never | |
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 155/89, BMI 30.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 6.2%, LDL 2.6 mmol/L, eGFR 73, ACR 1.0. Interpret in clinical context. | |
care_element | hba1c | 6.2 | |
care_element | albumin_creatinine_ratio | 1.0 | |
care_element | diastolic_bp | 89 | |
care_element | smoking_status | never | |
care_element | fasting_glucose | 5.1 | |
care_element | bmi | 27.0 | |
care_element | ldl_cholesterol | 2.6 | |
care_element | egfr | 73 | |
care_element | systolic_bp | 155 | |
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 154/88, BMI 29.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 6.1%, LDL 2.5 mmol/L, eGFR 72, ACR 0.9. Interpret in clinical context. | |
care_element | hba1c | 6.1 | |
care_element | systolic_bp | 154 | |
care_element | fasting_glucose | 5.0 | |
care_element | egfr | 72 | |
care_element | smoking_status | never | |
care_element | albumin_creatinine_ratio | 0.9 | |
care_element | diastolic_bp | 88 | |
care_element | ldl_cholesterol | 2.5 | |
care_element | bmi | 26.0 | |
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 153/87, BMI 28.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 6.0%, LDL 2.4 mmol/L, eGFR 71, ACR 0.8. Interpret in clinical context. | |
care_element | ldl_cholesterol | 2.4 | |
care_element | diastolic_bp | 87 | |
care_element | hba1c | 6.0 | |
care_element | bmi | 25.0 | |
care_element | albumin_creatinine_ratio | 0.8 | |
care_element | smoking_status | never | |
care_element | egfr | 71 | |
care_element | systolic_bp | 153 | |
care_element | fasting_glucose | 4.9 | |
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 152/86, BMI 27.8, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.9%, LDL 2.3 mmol/L, eGFR 70, ACR 0.7. Interpret in clinical context. | |
care_element | diastolic_bp | 86 | |
care_element | fasting_glucose | 4.8 | |
care_element | bmi | 24.0 | |
care_element | egfr | 70 | |
care_element | smoking_status | never | |
care_element | hba1c | 5.9 | |
care_element | ldl_cholesterol | 2.3 | |
care_element | systolic_bp | 152 | |
care_element | albumin_creatinine_ratio | 0.7 | |
appointment | Annual preventive visit | completed | |
appointment | Annual preventive visit | completed |
Lab panel: HbA1c 6.1%, LDL 2.5 mmol/L, eGFR 72, ACR 0.9. Interpret in clinical context.
132 mmHg
2026-03-15Diastolic Bp
92 mmHg
2026-03-15Bmi
30 kg/m2
2026-03-15Smoking Status
never
2026-03-15Hba1c
5.2 %
2025-02-14Fasting Glucose
5.3 mmol/L
2025-02-14Ldl Cholesterol
2.8 mmol/L
2025-02-14Egfr
75 mL/min/1.73m2
2025-02-14Albumin Creatinine Ratio
1.2 mg/mmol
2025-02-14Systolic Bp
157 mmHg
2025-02-14Diastolic Bp
91 mmHg
2025-02-14Bmi
29 kg/m2
2025-02-14Smoking Status
never
2025-02-14Hba1c
5.1 %
2024-01-13Fasting Glucose
5.2 mmol/L
2024-01-13Ldl Cholesterol
2.7 mmol/L
2024-01-13Egfr
74 mL/min/1.73m2
2024-01-13Albumin Creatinine Ratio
1.1 mg/mmol
2024-01-13Systolic Bp
156 mmHg
2024-01-13Diastolic Bp
90 mmHg
2024-01-13Bmi
28 kg/m2
2024-01-13Smoking Status
never
2024-01-13Hba1c
6.2 %
2023-12-12Fasting Glucose
5.1 mmol/L
2023-12-12Ldl Cholesterol
2.6 mmol/L
2023-12-12Egfr
73 mL/min/1.73m2
2023-12-12Albumin Creatinine Ratio
1 mg/mmol
2023-12-12Systolic Bp
155 mmHg
2023-12-12Diastolic Bp
89 mmHg
2023-12-12Bmi
27 kg/m2
2023-12-12Smoking Status
never
2023-12-12Hba1c
6.1 %
2022-11-11Fasting Glucose
5 mmol/L
2022-11-11Ldl Cholesterol
2.5 mmol/L
2022-11-11Egfr
72 mL/min/1.73m2
2022-11-11Albumin Creatinine Ratio
0.9 mg/mmol
2022-11-11Systolic Bp
154 mmHg
2022-11-11Diastolic Bp
88 mmHg
2022-11-11Bmi
26 kg/m2
2022-11-11Smoking Status
never
2022-11-11Hba1c
6 %
2021-10-10Fasting Glucose
4.9 mmol/L
2021-10-10Ldl Cholesterol
2.4 mmol/L
2021-10-10Egfr
71 mL/min/1.73m2
2021-10-10Albumin Creatinine Ratio
0.8 mg/mmol
2021-10-10Systolic Bp
153 mmHg
2021-10-10Diastolic Bp
87 mmHg
2021-10-10Bmi
25 kg/m2
2021-10-10Smoking Status
never
2021-10-10Hba1c
5.9 %
2020-09-09Fasting Glucose
4.8 mmol/L
2020-09-09Ldl Cholesterol
2.3 mmol/L
2020-09-09Egfr
70 mL/min/1.73m2
2020-09-09Albumin Creatinine Ratio
0.7 mg/mmol
2020-09-09Systolic Bp
152 mmHg
2020-09-09Diastolic Bp
86 mmHg
2020-09-09Bmi
24 kg/m2
2020-09-09Smoking Status
never
2020-09-09