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Population Health
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2, current
Mental Health review cohort
Chart evidence: Clinical note: SOAP note Diabetes follow-up S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherenc...
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 former synthetic-demo | Clinical note: SOAP note Diabetes follow-up S: Patient seen for longitudinal primary care follow-up. Reports v...
Open review tasks
2
New, in review, or accepted tasks
Last visit
2026-01-18
Appointment or derived chart contact
Latest A1c
7.6 %
2026-11-11
Latest BP
150 mmHg / 94 mmHg
2026-11-11
Extracted signals
0
Optional text signals
Chart volume
95
7 notes, 7 reports
A compact view of what needs attention before opening the full imported record.
Review priority
3
active signal
s
2
11
0
Review these before relying on the imported record clinically.
Review needed
2 open flags
Open clinical review items need status, assignment, or closure.
BP above target
Latest BP is 150 mmHg / 94 mmHg on 2026-11-11.
Future-dated imported records
Some source dates are after today's date and should be validated before clinical use.
Active problems
3
Type 2 diabetes mellitus
E11
active
Essential hypertension
I10
active
Depressive disorder
F32.9
active
Active medications
3
Metformin
500mg BID
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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81, 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 variable home glucose readings and medication adherence questions, with home BP readings sometimes above target. O: BP 126/82, BMI 25.2, cardiopulmonary exam stable, feet chec
report
Laboratory
Lab panel: HbA1c 7.6%, LDL 4.3 mmol/L, eGFR 89, ACR 0.9. Interpret in clinical context.
cohort_run
Cohort: Mental Health review cohort
completed | Chart evidence: 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 126/... | 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 125/... | 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 124/... | 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 123/... | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status former 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 126/... | 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 125/... | Care element: smoking_status former 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.
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 125/81, BMI 24.2, cardiopulmonary exam stable, feet chec
report
Laboratory
Lab panel: HbA1c 7.5%, LDL 4.2 mmol/L, eGFR 88, ACR 0.8. 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 124/80, BMI 23.2, cardiopulmonary exam stable, feet chec
report
Laboratory
Lab panel: HbA1c 7.4%, LDL 4.1 mmol/L, eGFR 87, ACR 0.7. Interpret in clinical context.
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 126/82, BMI 25.2, 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 125/81, BMI 24.2, 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 124/80, BMI 23.2, 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 123/79, BMI 36.2, 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 7.6%, LDL 4.3 mmol/L, eGFR 89, ACR 0.9. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 7.5%, LDL 4.2 mmol/L, eGFR 88, ACR 0.8. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 7.4%, LDL 4.1 mmol/L, eGFR 87, ACR 0.7. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 7.3%, LDL 4.0 mmol/L, eGFR 86, ACR 2.2. Interpret in clinical context.
Laboratory
Hba1c
7.6 %
2026-11-11Fasting Glucose
9.6 mmol/L
2026-11-11Ldl Cholesterol
4.3 mmol/L
2026-11-11Egfr
89 mL/min/1.73m2
2026-11-11Albumin Creatinine Ratio
0.9 mg/mmol
2026-11-11Systolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
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 126/82, BMI 25.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.6%, LDL 4.3 mmol/L, eGFR 89, ACR 0.9. Interpret in clinical context. | |
care_element | albumin_creatinine_ratio | 0.9 | |
care_element | hba1c | 7.6 | |
care_element | fasting_glucose | 9.6 | |
care_element | ldl_cholesterol | 4.3 | |
care_element | egfr | 89 | |
care_element | systolic_bp | 150 | |
care_element | bmi | 33.2 | |
care_element | diastolic_bp | 94 | |
care_element | smoking_status | former | |
cohort_run | Cohort: Mental Health review cohort | completed | Chart evidence: 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 126/... | 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 125/... | 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 124/... | 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 123/... | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status former 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 126/... | 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 125/... | Care element: smoking_status former 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. | |
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 125/81, BMI 24.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.5%, LDL 4.2 mmol/L, eGFR 88, ACR 0.8. Interpret in clinical context. | |
care_element | diastolic_bp | 93 | |
care_element | smoking_status | former | |
care_element | bmi | 32.2 | |
care_element | systolic_bp | 149 | |
care_element | albumin_creatinine_ratio | 0.8 | |
care_element | egfr | 88 | |
care_element | ldl_cholesterol | 4.2 | |
care_element | fasting_glucose | 9.5 | |
care_element | hba1c | 7.5 | |
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 124/80, BMI 23.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.4%, LDL 4.1 mmol/L, eGFR 87, ACR 0.7. Interpret in clinical context. | |
care_element | smoking_status | former | |
care_element | bmi | 31.2 | |
care_element | albumin_creatinine_ratio | 0.7 | |
care_element | diastolic_bp | 92 | |
care_element | systolic_bp | 148 | |
care_element | hba1c | 7.4 | |
care_element | fasting_glucose | 9.4 | |
care_element | egfr | 87 | |
care_element | ldl_cholesterol | 4.1 | |
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 123/79, BMI 36.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.3%, LDL 4.0 mmol/L, eGFR 86, ACR 2.2. Interpret in clinical context. | |
care_element | ldl_cholesterol | 4.0 | |
care_element | albumin_creatinine_ratio | 2.2 | |
care_element | hba1c | 7.3 | |
care_element | fasting_glucose | 9.3 | |
care_element | egfr | 86 | |
care_element | smoking_status | former | |
care_element | bmi | 30.2 | |
care_element | diastolic_bp | 91 | |
care_element | systolic_bp | 147 | |
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 122/78, BMI 35.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.2%, LDL 3.9 mmol/L, eGFR 85, ACR 2.1. Interpret in clinical context. | |
care_element | smoking_status | former | |
care_element | bmi | 29.2 | |
care_element | diastolic_bp | 90 | |
care_element | systolic_bp | 146 | |
care_element | albumin_creatinine_ratio | 2.1 | |
care_element | egfr | 85 | |
care_element | ldl_cholesterol | 3.9 | |
care_element | fasting_glucose | 9.2 | |
care_element | hba1c | 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 121/77, BMI 34.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.1%, LDL 3.8 mmol/L, eGFR 84, ACR 2.0. Interpret in clinical context. | |
care_element | smoking_status | former | |
care_element | egfr | 84 | |
care_element | ldl_cholesterol | 3.8 | |
care_element | fasting_glucose | 9.1 | |
care_element | hba1c | 7.1 | |
care_element | systolic_bp | 145 | |
care_element | albumin_creatinine_ratio | 2.0 | |
care_element | diastolic_bp | 89 | |
care_element | bmi | 28.2 | |
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 120/76, BMI 33.2, cardiopulmonary exam stable, feet chec | |
report | Laboratory | Lab panel: HbA1c 7.0%, LDL 3.7 mmol/L, eGFR 83, ACR 1.9. Interpret in clinical context. | |
care_element | hba1c | 7.0 | |
care_element | egfr | 83 | |
care_element | albumin_creatinine_ratio | 1.9 | |
care_element | smoking_status | former | |
care_element | fasting_glucose | 9.0 | |
care_element | ldl_cholesterol | 3.7 | |
care_element | systolic_bp | 144 | |
care_element | diastolic_bp | 88 | |
care_element | bmi | 27.2 | |
appointment | Chronic disease follow-up | completed |
Lab panel: HbA1c 7.2%, LDL 3.9 mmol/L, eGFR 85, ACR 2.1. Interpret in clinical context.
150 mmHg
2026-11-11Diastolic Bp
94 mmHg
2026-11-11Bmi
33.2 kg/m2
2026-11-11Smoking Status
former
2026-11-11Hba1c
7.5 %
2025-10-10Fasting Glucose
9.5 mmol/L
2025-10-10Ldl Cholesterol
4.2 mmol/L
2025-10-10Egfr
88 mL/min/1.73m2
2025-10-10Albumin Creatinine Ratio
0.8 mg/mmol
2025-10-10Systolic Bp
149 mmHg
2025-10-10Diastolic Bp
93 mmHg
2025-10-10Bmi
32.2 kg/m2
2025-10-10Smoking Status
former
2025-10-10Hba1c
7.4 %
2024-09-09Fasting Glucose
9.4 mmol/L
2024-09-09Ldl Cholesterol
4.1 mmol/L
2024-09-09Egfr
87 mL/min/1.73m2
2024-09-09Albumin Creatinine Ratio
0.7 mg/mmol
2024-09-09Systolic Bp
148 mmHg
2024-09-09Diastolic Bp
92 mmHg
2024-09-09Bmi
31.2 kg/m2
2024-09-09Smoking Status
former
2024-09-09Hba1c
7.3 %
2023-08-08Fasting Glucose
9.3 mmol/L
2023-08-08Ldl Cholesterol
4 mmol/L
2023-08-08Egfr
86 mL/min/1.73m2
2023-08-08Albumin Creatinine Ratio
2.2 mg/mmol
2023-08-08Systolic Bp
147 mmHg
2023-08-08Diastolic Bp
91 mmHg
2023-08-08Bmi
30.2 kg/m2
2023-08-08Smoking Status
former
2023-08-08Hba1c
7.2 %
2022-07-07Fasting Glucose
9.2 mmol/L
2022-07-07Ldl Cholesterol
3.9 mmol/L
2022-07-07Egfr
85 mL/min/1.73m2
2022-07-07Albumin Creatinine Ratio
2.1 mg/mmol
2022-07-07Systolic Bp
146 mmHg
2022-07-07Diastolic Bp
90 mmHg
2022-07-07Bmi
29.2 kg/m2
2022-07-07Smoking Status
former
2022-07-07Hba1c
7.1 %
2021-06-06Fasting Glucose
9.1 mmol/L
2021-06-06Ldl Cholesterol
3.8 mmol/L
2021-06-06Egfr
84 mL/min/1.73m2
2021-06-06Albumin Creatinine Ratio
2 mg/mmol
2021-06-06Systolic Bp
145 mmHg
2021-06-06Diastolic Bp
89 mmHg
2021-06-06Bmi
28.2 kg/m2
2021-06-06Smoking Status
former
2021-06-06Hba1c
7 %
2020-05-05Fasting Glucose
9 mmol/L
2020-05-05Ldl Cholesterol
3.7 mmol/L
2020-05-05Egfr
83 mL/min/1.73m2
2020-05-05Albumin Creatinine Ratio
1.9 mg/mmol
2020-05-05Systolic Bp
144 mmHg
2020-05-05Diastolic Bp
88 mmHg
2020-05-05Bmi
27.2 kg/m2
2020-05-05Smoking Status
former
2020-05-05