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1, current
Smoking / Lung Screening review cohort
Chart evidence: Care element: smoking_status current synthetic-demo | Clinical note: SOAP note Hypertension follow-up S: Patient seen for longitudinal primary care follow-up. Repo...
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2
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Last visit
2026-01-25
Appointment or derived chart contact
Latest A1c
5.8 %
2026-08-20
Latest BP
137 mmHg / 83 mmHg
2026-08-20
Extracted signals
0
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Chart volume
93
7 notes, 7 reports
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Review priority
2
active signal
s
2
11
0
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2 open flags
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Future-dated imported records
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Active problems
2
Essential hypertension
I10
active
Chronic kidney disease stage 3
N18.3
active
Active medications
2
Metformin
500mg BID
Ramipril
5mg daily
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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 125/79, BMI 34.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.8%, LDL 3.4 mmol/L, eGFR 49, ACR 5.9. Interpret in clinical context.
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status current 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 125/79, BMI 34.3, 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 124/78, BMI 33.3, cardiopulmonary... | Care element: smoking_status current 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.
clinical_flag
Synthetic CKD surveillance review
new | high | synthetic_longitudinal_data | Synthetic eGFR/ACR trend suggests CKD surveillance should be reviewed.
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 124/78, BMI 33.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.7%, LDL 3.3 mmol/L, eGFR 48, ACR 5.8. 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 123/77, BMI 32.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.6%, LDL 3.2 mmol/L, eGFR 47, ACR 5.7. 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 125/79, BMI 34.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care review; hypertension monitoring; 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 home BP readings sometimes above target. O: BP 124/78, BMI 33.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care review; hypertension monitoring; 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 home BP readings sometimes above target. O: BP 123/77, BMI 32.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care review; hypertension monitoring; 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 home BP readings sometimes above target. O: BP 122/76, BMI 31.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Preventive care review; hypertension monitoring; 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.
Laboratory
Lab panel: HbA1c 5.8%, LDL 3.4 mmol/L, eGFR 49, ACR 5.9. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 5.7%, LDL 3.3 mmol/L, eGFR 48, ACR 5.8. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 5.6%, LDL 3.2 mmol/L, eGFR 47, ACR 5.7. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 5.5%, LDL 3.1 mmol/L, eGFR 46, ACR 5.6. Interpret in clinical context.
Laboratory
Hba1c
5.8 %
2026-08-20Fasting Glucose
5.9 mmol/L
2026-08-20Ldl Cholesterol
3.4 mmol/L
2026-08-20Egfr
49 mL/min/1.73m2
2026-08-20Albumin Creatinine Ratio
5.9 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 125/79, BMI 34.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.8%, LDL 3.4 mmol/L, eGFR 49, ACR 5.9. Interpret in clinical context. | |
care_element | smoking_status | current | |
care_element | ldl_cholesterol | 3.4 | |
care_element | hba1c | 5.8 | |
care_element | bmi | 23.5 | |
care_element | fasting_glucose | 5.9 | |
care_element | egfr | 49 | |
care_element | systolic_bp | 137 | |
care_element | diastolic_bp | 83 | |
care_element | albumin_creatinine_ratio | 5.9 | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status current 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 125/79, BMI 34.3, 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 124/78, BMI 33.3, cardiopulmonary... | Care element: smoking_status current 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. | |
clinical_flag | Synthetic CKD surveillance review | new | high | synthetic_longitudinal_data | Synthetic eGFR/ACR trend suggests CKD surveillance should be reviewed. | |
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 124/78, BMI 33.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.7%, LDL 3.3 mmol/L, eGFR 48, ACR 5.8. Interpret in clinical context. | |
care_element | bmi | 22.5 | |
care_element | albumin_creatinine_ratio | 5.8 | |
care_element | ldl_cholesterol | 3.3 | |
care_element | egfr | 48 | |
care_element | fasting_glucose | 5.8 | |
care_element | systolic_bp | 136 | |
care_element | diastolic_bp | 82 | |
care_element | hba1c | 5.7 | |
care_element | smoking_status | current | |
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 123/77, BMI 32.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.6%, LDL 3.2 mmol/L, eGFR 47, ACR 5.7. Interpret in clinical context. | |
care_element | fasting_glucose | 5.7 | |
care_element | systolic_bp | 135 | |
care_element | smoking_status | current | |
care_element | albumin_creatinine_ratio | 5.7 | |
care_element | ldl_cholesterol | 3.2 | |
care_element | bmi | 38.5 | |
care_element | hba1c | 5.6 | |
care_element | diastolic_bp | 95 | |
care_element | egfr | 47 | |
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 122/76, BMI 31.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.5%, LDL 3.1 mmol/L, eGFR 46, ACR 5.6. Interpret in clinical context. | |
care_element | albumin_creatinine_ratio | 5.6 | |
care_element | diastolic_bp | 94 | |
care_element | bmi | 37.5 | |
care_element | fasting_glucose | 5.6 | |
care_element | smoking_status | current | |
care_element | systolic_bp | 134 | |
care_element | hba1c | 5.5 | |
care_element | egfr | 46 | |
care_element | ldl_cholesterol | 3.1 | |
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 121/75, BMI 30.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.4%, LDL 3.0 mmol/L, eGFR 45, ACR 5.5. Interpret in clinical context. | |
care_element | fasting_glucose | 5.5 | |
care_element | egfr | 45 | |
care_element | hba1c | 5.4 | |
care_element | diastolic_bp | 93 | |
care_element | ldl_cholesterol | 3.0 | |
care_element | bmi | 36.5 | |
care_element | albumin_creatinine_ratio | 5.5 | |
care_element | smoking_status | current | |
care_element | systolic_bp | 133 | |
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 120/74, BMI 29.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.3%, LDL 2.9 mmol/L, eGFR 44, ACR 5.4. Interpret in clinical context. | |
care_element | egfr | 44 | |
care_element | bmi | 35.5 | |
care_element | fasting_glucose | 5.4 | |
care_element | smoking_status | current | |
care_element | systolic_bp | 132 | |
care_element | diastolic_bp | 92 | |
care_element | hba1c | 5.3 | |
care_element | ldl_cholesterol | 2.9 | |
care_element | albumin_creatinine_ratio | 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 119/73, BMI 28.3, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.2%, LDL 2.8 mmol/L, eGFR 43, ACR 5.3. Interpret in clinical context. | |
care_element | systolic_bp | 157 | |
care_element | albumin_creatinine_ratio | 5.3 | |
care_element | smoking_status | current | |
care_element | fasting_glucose | 5.3 | |
care_element | bmi | 34.5 | |
care_element | hba1c | 5.2 | |
care_element | ldl_cholesterol | 2.8 | |
care_element | diastolic_bp | 91 | |
care_element | egfr | 43 | |
appointment | Annual preventive visit | completed |
Lab panel: HbA1c 5.4%, LDL 3.0 mmol/L, eGFR 45, ACR 5.5. Interpret in clinical context.
137 mmHg
2026-08-20Diastolic Bp
83 mmHg
2026-08-20Bmi
23.5 kg/m2
2026-08-20Smoking Status
current
2026-08-20Hba1c
5.7 %
2025-07-19Fasting Glucose
5.8 mmol/L
2025-07-19Ldl Cholesterol
3.3 mmol/L
2025-07-19Egfr
48 mL/min/1.73m2
2025-07-19Albumin Creatinine Ratio
5.8 mg/mmol
2025-07-19Systolic Bp
136 mmHg
2025-07-19Diastolic Bp
82 mmHg
2025-07-19Bmi
22.5 kg/m2
2025-07-19Smoking Status
current
2025-07-19Hba1c
5.6 %
2024-06-18Fasting Glucose
5.7 mmol/L
2024-06-18Ldl Cholesterol
3.2 mmol/L
2024-06-18Egfr
47 mL/min/1.73m2
2024-06-18Albumin Creatinine Ratio
5.7 mg/mmol
2024-06-18Systolic Bp
135 mmHg
2024-06-18Diastolic Bp
95 mmHg
2024-06-18Bmi
38.5 kg/m2
2024-06-18Smoking Status
current
2024-06-18Hba1c
5.5 %
2023-05-17Fasting Glucose
5.6 mmol/L
2023-05-17Ldl Cholesterol
3.1 mmol/L
2023-05-17Egfr
46 mL/min/1.73m2
2023-05-17Albumin Creatinine Ratio
5.6 mg/mmol
2023-05-17Systolic Bp
134 mmHg
2023-05-17Diastolic Bp
94 mmHg
2023-05-17Bmi
37.5 kg/m2
2023-05-17Smoking Status
current
2023-05-17Hba1c
5.4 %
2022-04-16Fasting Glucose
5.5 mmol/L
2022-04-16Ldl Cholesterol
3 mmol/L
2022-04-16Egfr
45 mL/min/1.73m2
2022-04-16Albumin Creatinine Ratio
5.5 mg/mmol
2022-04-16Systolic Bp
133 mmHg
2022-04-16Diastolic Bp
93 mmHg
2022-04-16Bmi
36.5 kg/m2
2022-04-16Smoking Status
current
2022-04-16Hba1c
5.3 %
2021-03-15Fasting Glucose
5.4 mmol/L
2021-03-15Ldl Cholesterol
2.9 mmol/L
2021-03-15Egfr
44 mL/min/1.73m2
2021-03-15Albumin Creatinine Ratio
5.4 mg/mmol
2021-03-15Systolic Bp
132 mmHg
2021-03-15Diastolic Bp
92 mmHg
2021-03-15Bmi
35.5 kg/m2
2021-03-15Smoking Status
current
2021-03-15Hba1c
5.2 %
2020-02-14Fasting Glucose
5.3 mmol/L
2020-02-14Ldl Cholesterol
2.8 mmol/L
2020-02-14Egfr
43 mL/min/1.73m2
2020-02-14Albumin Creatinine Ratio
5.3 mg/mmol
2020-02-14Systolic Bp
157 mmHg
2020-02-14Diastolic Bp
91 mmHg
2020-02-14Bmi
34.5 kg/m2
2020-02-14Smoking Status
current
2020-02-14