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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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1
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Last visit
2026-02-02
Appointment or derived chart contact
Latest A1c
5.3 %
2026-03-03
Latest BP
142 mmHg / 86 mmHg
2026-03-03
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
0
0
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Review needed
1 open flag
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BP above target
Latest BP is 142 mmHg / 86 mmHg on 2026-03-03.
Active problems
2
Essential hypertension
I10
active
Dyslipidemia
E78.5
active
Active medications
2
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 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 118/74, BMI 29.4, 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 155/73, BMI 28.4, 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 118/74, BMI 29.4, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.3%, LDL 3.5 mmol/L, eGFR 81, ACR 1.7. 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 155/73, BMI 28.4, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.2%, LDL 3.4 mmol/L, eGFR 80, ACR 1.6. Interpret in clinical context.
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 154/72, BMI 27.4, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre
report
Laboratory
Lab panel: HbA1c 5.1%, LDL 3.3 mmol/L, eGFR 79, ACR 1.5. 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 118/74, BMI 29.4, 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 155/73, BMI 28.4, 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 154/72, BMI 27.4, 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 153/89, BMI 26.4, 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 3.5 mmol/L, eGFR 81, ACR 1.7. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 5.2%, LDL 3.4 mmol/L, eGFR 80, ACR 1.6. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 5.1%, LDL 3.3 mmol/L, eGFR 79, ACR 1.5. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 6.2%, LDL 3.2 mmol/L, eGFR 78, ACR 1.4. Interpret in clinical context.
Laboratory
Hba1c
5.3 %
2026-03-03Fasting Glucose
5.8 mmol/L
2026-03-03Ldl Cholesterol
3.5 mmol/L
2026-03-03Egfr
81 mL/min/1.73m2
2026-03-03Albumin Creatinine Ratio
1.7 mg/mmol
2026-03-03Systolic 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 118/74, BMI 29.4, 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 155/73, BMI 28.4, 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 118/74, BMI 29.4, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.3%, LDL 3.5 mmol/L, eGFR 81, ACR 1.7. Interpret in clinical context. | |
care_element | systolic_bp | 142 | |
care_element | diastolic_bp | 86 | |
care_element | fasting_glucose | 5.8 | |
care_element | bmi | 34.1 | |
care_element | albumin_creatinine_ratio | 1.7 | |
care_element | smoking_status | never | |
care_element | egfr | 81 | |
care_element | ldl_cholesterol | 3.5 | |
care_element | hba1c | 5.3 | |
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 155/73, BMI 28.4, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.2%, LDL 3.4 mmol/L, eGFR 80, ACR 1.6. Interpret in clinical context. | |
care_element | egfr | 80 | |
appointment | Annual preventive visit | completed | |
care_element | systolic_bp | 141 | |
care_element | smoking_status | never | |
care_element | ldl_cholesterol | 3.4 | |
care_element | albumin_creatinine_ratio | 1.6 | |
care_element | hba1c | 5.2 | |
care_element | bmi | 33.1 | |
care_element | diastolic_bp | 85 | |
care_element | fasting_glucose | 5.7 | |
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 154/72, BMI 27.4, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.1%, LDL 3.3 mmol/L, eGFR 79, ACR 1.5. Interpret in clinical context. | |
care_element | systolic_bp | 140 | |
care_element | smoking_status | never | |
care_element | ldl_cholesterol | 3.3 | |
care_element | albumin_creatinine_ratio | 1.5 | |
care_element | fasting_glucose | 5.6 | |
care_element | bmi | 32.1 | |
care_element | hba1c | 5.1 | |
care_element | diastolic_bp | 84 | |
care_element | egfr | 79 | |
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 153/89, BMI 26.4, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 6.2%, LDL 3.2 mmol/L, eGFR 78, ACR 1.4. Interpret in clinical context. | |
care_element | diastolic_bp | 83 | |
care_element | systolic_bp | 139 | |
care_element | albumin_creatinine_ratio | 1.4 | |
care_element | ldl_cholesterol | 3.2 | |
care_element | fasting_glucose | 5.5 | |
care_element | bmi | 31.1 | |
care_element | smoking_status | never | |
care_element | egfr | 78 | |
care_element | hba1c | 6.2 | |
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 152/88, BMI 25.4, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 6.1%, LDL 3.1 mmol/L, eGFR 77, ACR 1.3. Interpret in clinical context. | |
care_element | hba1c | 6.1 | |
care_element | systolic_bp | 138 | |
care_element | fasting_glucose | 5.4 | |
care_element | egfr | 77 | |
care_element | smoking_status | never | |
care_element | albumin_creatinine_ratio | 1.3 | |
care_element | diastolic_bp | 82 | |
care_element | ldl_cholesterol | 3.1 | |
care_element | bmi | 30.1 | |
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 151/87, BMI 24.4, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 6.0%, LDL 3.0 mmol/L, eGFR 76, ACR 1.2. Interpret in clinical context. | |
care_element | ldl_cholesterol | 3.0 | |
care_element | diastolic_bp | 95 | |
care_element | hba1c | 6.0 | |
care_element | bmi | 29.1 | |
care_element | albumin_creatinine_ratio | 1.2 | |
care_element | smoking_status | never | |
care_element | egfr | 76 | |
care_element | systolic_bp | 137 | |
care_element | fasting_glucose | 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 150/86, BMI 23.4, cardiopulmonary exam stable, feet checked when diabetes present. A: Pre | |
report | Laboratory | Lab panel: HbA1c 5.9%, LDL 2.9 mmol/L, eGFR 75, ACR 1.1. Interpret in clinical context. | |
care_element | diastolic_bp | 94 | |
care_element | fasting_glucose | 5.2 | |
care_element | bmi | 28.1 | |
care_element | egfr | 75 | |
care_element | smoking_status | never | |
care_element | hba1c | 5.9 | |
care_element | ldl_cholesterol | 2.9 | |
care_element | systolic_bp | 136 | |
care_element | albumin_creatinine_ratio | 1.1 | |
appointment | Annual preventive visit | completed | |
appointment | Annual preventive visit | completed |
Lab panel: HbA1c 6.1%, LDL 3.1 mmol/L, eGFR 77, ACR 1.3. Interpret in clinical context.
142 mmHg
2026-03-03Diastolic Bp
86 mmHg
2026-03-03Bmi
34.1 kg/m2
2026-03-03Smoking Status
never
2026-03-03Hba1c
5.2 %
2025-02-02Fasting Glucose
5.7 mmol/L
2025-02-02Ldl Cholesterol
3.4 mmol/L
2025-02-02Egfr
80 mL/min/1.73m2
2025-02-02Albumin Creatinine Ratio
1.6 mg/mmol
2025-02-02Systolic Bp
141 mmHg
2025-02-02Diastolic Bp
85 mmHg
2025-02-02Bmi
33.1 kg/m2
2025-02-02Smoking Status
never
2025-02-02Hba1c
5.1 %
2024-01-01Fasting Glucose
5.6 mmol/L
2024-01-01Ldl Cholesterol
3.3 mmol/L
2024-01-01Egfr
79 mL/min/1.73m2
2024-01-01Albumin Creatinine Ratio
1.5 mg/mmol
2024-01-01Systolic Bp
140 mmHg
2024-01-01Diastolic Bp
84 mmHg
2024-01-01Bmi
32.1 kg/m2
2024-01-01Smoking Status
never
2024-01-01Hba1c
6.2 %
2023-12-24Fasting Glucose
5.5 mmol/L
2023-12-24Ldl Cholesterol
3.2 mmol/L
2023-12-24Egfr
78 mL/min/1.73m2
2023-12-24Albumin Creatinine Ratio
1.4 mg/mmol
2023-12-24Systolic Bp
139 mmHg
2023-12-24Diastolic Bp
83 mmHg
2023-12-24Bmi
31.1 kg/m2
2023-12-24Smoking Status
never
2023-12-24Hba1c
6.1 %
2022-11-23Fasting Glucose
5.4 mmol/L
2022-11-23Ldl Cholesterol
3.1 mmol/L
2022-11-23Egfr
77 mL/min/1.73m2
2022-11-23Albumin Creatinine Ratio
1.3 mg/mmol
2022-11-23Systolic Bp
138 mmHg
2022-11-23Diastolic Bp
82 mmHg
2022-11-23Bmi
30.1 kg/m2
2022-11-23Smoking Status
never
2022-11-23Hba1c
6 %
2021-10-22Fasting Glucose
5.3 mmol/L
2021-10-22Ldl Cholesterol
3 mmol/L
2021-10-22Egfr
76 mL/min/1.73m2
2021-10-22Albumin Creatinine Ratio
1.2 mg/mmol
2021-10-22Systolic Bp
137 mmHg
2021-10-22Diastolic Bp
95 mmHg
2021-10-22Bmi
29.1 kg/m2
2021-10-22Smoking Status
never
2021-10-22Hba1c
5.9 %
2020-09-21Fasting Glucose
5.2 mmol/L
2020-09-21Ldl Cholesterol
2.9 mmol/L
2020-09-21Egfr
75 mL/min/1.73m2
2020-09-21Albumin Creatinine Ratio
1.1 mg/mmol
2020-09-21Systolic Bp
136 mmHg
2020-09-21Diastolic Bp
94 mmHg
2020-09-21Bmi
28.1 kg/m2
2020-09-21Smoking Status
never
2020-09-21