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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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2
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Last visit
2026-01-21
Appointment or derived chart contact
Latest A1c
8 %
2026-03-15
Latest BP
156 mmHg / 88 mmHg
2026-03-15
Extracted signals
0
Optional text signals
Chart volume
94
7 notes, 7 reports
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Review priority
3
active signal
s
2
0
0
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Review needed
2 open flags
Open clinical review items need status, assignment, or closure.
A1c above review threshold
Latest HbA1c is 8 % on 2026-03-15.
BP above target
Latest BP is 156 mmHg / 88 mmHg on 2026-03-15.
Active problems
3
Type 2 diabetes mellitus
E11
active
Essential hypertension
I10
active
Dyslipidemia
E78.5
active
Active medications
3
Metformin
500mg BID
Ramipril
5mg daily
Rosuvastatin
10mg daily
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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 Diabetes follow-up S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with home BP readings sometimes above target. O: BP 144/... | 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 home BP readings sometimes above target. O: BP 143/... | Care element: smoking_status never synthetic-demo | probable
alert
Diabetes monitoring due soon
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.
clinical_flag
Synthetic diabetes monitoring review
new | medium | synthetic_longitudinal_data | Longitudinal synthetic data suggests diabetes with recent monitoring possibly due.
note
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with home BP readings sometimes above target. O: BP 144/80, BMI 35.2, cardiopulmonary exam stable, feet chec
report
Laboratory
Lab panel: HbA1c 8.0%, LDL 2.3 mmol/L, eGFR 69, ACR 2.1. 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 home BP readings sometimes above target. O: BP 143/79, BMI 34.2, cardiopulmonary exam stable, feet chec
report
Laboratory
Lab panel: HbA1c 7.9%, LDL 2.2 mmol/L, eGFR 68, ACR 2.0. Interpret in clinical context.
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 home BP readings sometimes above target. O: BP 142/78, BMI 33.2, cardiopulmonary exam stable, feet chec
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with home BP readings sometimes above target. O: BP 144/80, BMI 35.2, cardiopulmonary exam stable, feet checked when diabetes present. A: Type 2 diabetes follow-up; 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 variable home glucose readings and medication adherence questions, with home BP readings sometimes above target. O: BP 143/79, BMI 34.2, cardiopulmonary exam stable, feet checked when diabetes present. A: Type 2 diabetes follow-up; 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 variable home glucose readings and medication adherence questions, with home BP readings sometimes above target. O: BP 142/78, BMI 33.2, cardiopulmonary exam stable, feet checked when diabetes present. A: Type 2 diabetes follow-up; 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 variable home glucose readings and medication adherence questions, with home BP readings sometimes above target. O: BP 141/77, BMI 32.2, cardiopulmonary exam stable, feet checked when diabetes present. A: Type 2 diabetes follow-up; 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 diabetes monitoring review
Longitudinal synthetic data suggests diabetes with recent monitoring possibly due.
Synthetic BP follow-up review
Several synthetic BP readings are above target and need clinician review.
Laboratory
Lab panel: HbA1c 8.0%, LDL 2.3 mmol/L, eGFR 69, ACR 2.1. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 7.9%, LDL 2.2 mmol/L, eGFR 68, ACR 2.0. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 7.8%, LDL 2.1 mmol/L, eGFR 98, ACR 1.9. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 7.7%, LDL 2.0 mmol/L, eGFR 97, ACR 1.8. Interpret in clinical context.
Laboratory
Hba1c
8 %
2026-03-15Fasting Glucose
7.6 mmol/L
2026-03-15Ldl Cholesterol
2.3 mmol/L
2026-03-15Egfr
69 mL/min/1.73m2
2026-03-15Albumin Creatinine Ratio
2.1 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 Diabetes follow-up S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with home BP readings sometimes above target. O: BP 144/... | 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 home BP readings sometimes above target. O: BP 143/... | Care element: smoking_status never synthetic-demo | probable | |
alert | Diabetes monitoring due soon | 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. | |
clinical_flag | Synthetic diabetes monitoring review | new | medium | synthetic_longitudinal_data | Longitudinal synthetic data suggests diabetes with recent monitoring possibly due. | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with home BP readings sometimes above target. O: BP 144/80, BMI 35.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 8.0%, LDL 2.3 mmol/L, eGFR 69, ACR 2.1. Interpret in clinical context. | |
care_element | ldl_cholesterol | 2.3 | |
care_element | fasting_glucose | 7.6 | |
care_element | bmi | 27.3 | |
care_element | smoking_status | never | |
care_element | albumin_creatinine_ratio | 2.1 | |
care_element | egfr | 69 | |
care_element | hba1c | 8.0 | |
care_element | diastolic_bp | 88 | |
care_element | systolic_bp | 156 | |
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 home BP readings sometimes above target. O: BP 143/79, BMI 34.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.9%, LDL 2.2 mmol/L, eGFR 68, ACR 2.0. Interpret in clinical context. | |
care_element | systolic_bp | 155 | |
care_element | smoking_status | never | |
care_element | bmi | 26.3 | |
care_element | diastolic_bp | 87 | |
care_element | albumin_creatinine_ratio | 2.0 | |
care_element | egfr | 68 | |
care_element | ldl_cholesterol | 2.2 | |
care_element | fasting_glucose | 7.5 | |
care_element | hba1c | 7.9 | |
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 home BP readings sometimes above target. O: BP 142/78, BMI 33.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.8%, LDL 2.1 mmol/L, eGFR 98, ACR 1.9. Interpret in clinical context. | |
care_element | egfr | 98 | |
care_element | smoking_status | never | |
care_element | bmi | 25.3 | |
care_element | fasting_glucose | 7.4 | |
care_element | ldl_cholesterol | 2.1 | |
care_element | hba1c | 7.8 | |
care_element | diastolic_bp | 86 | |
care_element | albumin_creatinine_ratio | 1.9 | |
care_element | systolic_bp | 154 | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with home BP readings sometimes above target. O: BP 141/77, BMI 32.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.7%, LDL 2.0 mmol/L, eGFR 97, ACR 1.8. Interpret in clinical context. | |
care_element | systolic_bp | 153 | |
care_element | ldl_cholesterol | 2.0 | |
care_element | fasting_glucose | 7.3 | |
care_element | hba1c | 7.7 | |
care_element | smoking_status | never | |
care_element | bmi | 24.3 | |
care_element | diastolic_bp | 85 | |
care_element | albumin_creatinine_ratio | 1.8 | |
care_element | egfr | 97 | |
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 home BP readings sometimes above target. O: BP 140/76, BMI 31.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.6%, LDL 1.9 mmol/L, eGFR 96, ACR 1.7. Interpret in clinical context. | |
care_element | hba1c | 7.6 | |
care_element | smoking_status | never | |
care_element | bmi | 23.3 | |
care_element | diastolic_bp | 84 | |
care_element | systolic_bp | 152 | |
care_element | albumin_creatinine_ratio | 1.7 | |
care_element | egfr | 96 | |
care_element | ldl_cholesterol | 1.9 | |
care_element | fasting_glucose | 7.2 | |
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 home BP readings sometimes above target. O: BP 139/75, BMI 30.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.5%, LDL 1.8 mmol/L, eGFR 95, ACR 1.6. Interpret in clinical context. | |
care_element | albumin_creatinine_ratio | 1.6 | |
care_element | egfr | 95 | |
care_element | ldl_cholesterol | 1.8 | |
care_element | fasting_glucose | 7.1 | |
care_element | hba1c | 7.5 | |
care_element | smoking_status | never | |
care_element | bmi | 22.3 | |
care_element | diastolic_bp | 83 | |
care_element | systolic_bp | 151 | |
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 home BP readings sometimes above target. O: BP 138/74, BMI 29.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.4%, LDL 1.7 mmol/L, eGFR 94, ACR 1.5. Interpret in clinical context. | |
care_element | smoking_status | never | |
care_element | bmi | 38.3 | |
care_element | diastolic_bp | 82 | |
care_element | systolic_bp | 150 | |
care_element | albumin_creatinine_ratio | 1.5 | |
care_element | egfr | 94 | |
care_element | ldl_cholesterol | 1.7 | |
care_element | fasting_glucose | 7.0 | |
care_element | hba1c | 7.4 | |
appointment | Chronic disease follow-up | completed | |
appointment | Chronic disease follow-up | completed |
Lab panel: HbA1c 7.6%, LDL 1.9 mmol/L, eGFR 96, ACR 1.7. Interpret in clinical context.
156 mmHg
2026-03-15Diastolic Bp
88 mmHg
2026-03-15Bmi
27.3 kg/m2
2026-03-15Smoking Status
never
2026-03-15Hba1c
7.9 %
2025-02-14Fasting Glucose
7.5 mmol/L
2025-02-14Ldl Cholesterol
2.2 mmol/L
2025-02-14Egfr
68 mL/min/1.73m2
2025-02-14Albumin Creatinine Ratio
2 mg/mmol
2025-02-14Systolic Bp
155 mmHg
2025-02-14Diastolic Bp
87 mmHg
2025-02-14Bmi
26.3 kg/m2
2025-02-14Smoking Status
never
2025-02-14Hba1c
7.8 %
2024-01-13Fasting Glucose
7.4 mmol/L
2024-01-13Ldl Cholesterol
2.1 mmol/L
2024-01-13Egfr
98 mL/min/1.73m2
2024-01-13Albumin Creatinine Ratio
1.9 mg/mmol
2024-01-13Systolic Bp
154 mmHg
2024-01-13Diastolic Bp
86 mmHg
2024-01-13Bmi
25.3 kg/m2
2024-01-13Smoking Status
never
2024-01-13Systolic Bp
153 mmHg
2023-12-12Hba1c
7.7 %
2023-12-12Fasting Glucose
7.3 mmol/L
2023-12-12Ldl Cholesterol
2 mmol/L
2023-12-12Egfr
97 mL/min/1.73m2
2023-12-12Albumin Creatinine Ratio
1.8 mg/mmol
2023-12-12Diastolic Bp
85 mmHg
2023-12-12Bmi
24.3 kg/m2
2023-12-12Smoking Status
never
2023-12-12Hba1c
7.6 %
2022-11-11Fasting Glucose
7.2 mmol/L
2022-11-11Ldl Cholesterol
1.9 mmol/L
2022-11-11Egfr
96 mL/min/1.73m2
2022-11-11Albumin Creatinine Ratio
1.7 mg/mmol
2022-11-11Systolic Bp
152 mmHg
2022-11-11Diastolic Bp
84 mmHg
2022-11-11Bmi
23.3 kg/m2
2022-11-11Smoking Status
never
2022-11-11Hba1c
7.5 %
2021-10-10Fasting Glucose
7.1 mmol/L
2021-10-10Ldl Cholesterol
1.8 mmol/L
2021-10-10Egfr
95 mL/min/1.73m2
2021-10-10Albumin Creatinine Ratio
1.6 mg/mmol
2021-10-10Systolic Bp
151 mmHg
2021-10-10Diastolic Bp
83 mmHg
2021-10-10Bmi
22.3 kg/m2
2021-10-10Smoking Status
never
2021-10-10Hba1c
7.4 %
2020-09-09Fasting Glucose
7 mmol/L
2020-09-09Ldl Cholesterol
1.7 mmol/L
2020-09-09Egfr
94 mL/min/1.73m2
2020-09-09Albumin Creatinine Ratio
1.5 mg/mmol
2020-09-09Systolic Bp
150 mmHg
2020-09-09Diastolic Bp
82 mmHg
2020-09-09Bmi
38.3 kg/m2
2020-09-09Smoking Status
never
2020-09-09