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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
2026-02-05
Appointment or derived chart contact
Latest A1c
7 %
2026-05-05
Latest BP
116 mmHg / 78 mmHg
2026-05-05
Extracted signals
0
Optional text signals
Chart volume
95
7 notes, 7 reports
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Review priority
1
active signal
2
0
0
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Review needed
2 open flags
Open clinical review items need status, assignment, or closure.
Active problems
3
Type 2 diabetes mellitus
E11
active
Chronic kidney disease stage 3
N18.3
active
Depressive disorder
F32.9
active
Active medications
3
Metformin
500mg BID
Ramipril
5mg daily
Sertraline
50mg daily
membership needs review
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81, more source rows below
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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 no major interval concerns. O: BP 144/82, BMI 23.0,... | 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 no major interval concerns. O: BP 143/81, BMI 36.0,... | 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 no major interval concerns. O: BP 142/80, BMI 35.0,... | 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 no major interval concerns. O: BP 141/79, BMI 34.0,... | 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 no major interval concerns. O: BP 144/82, BMI 23.0,... | 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 no major interval concerns. O: BP 143/81, BMI 36.0,... | Care element: smoking_status former synthetic-demo | probable
alert
Renal function requires ongoing monitoring
Synthetic alert for testing active cohort and review workflows.
clinical_flag
Synthetic CKD surveillance review
new | high | synthetic_longitudinal_data | Synthetic eGFR/ACR trend suggests CKD surveillance should be reviewed.
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 no major interval concerns. O: BP 144/82, BMI 23.0, cardiopulmonary exam stable, feet checked when diab
report
Laboratory
Lab panel: HbA1c 7.0%, LDL 3.1 mmol/L, eGFR 52, ACR 5.6. 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 no major interval concerns. O: BP 143/81, BMI 36.0, cardiopulmonary exam stable, feet checked when diab
report
Laboratory
Lab panel: HbA1c 6.9%, LDL 3.0 mmol/L, eGFR 51, ACR 5.5. 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 no major interval concerns. O: BP 142/80, BMI 35.0, cardiopulmonary exam stable, feet checked when diab
SOAP note
S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 144/82, BMI 23.0, cardiopulmonary exam stable, feet checked when diabetes present. A: Type 2 diabetes follow-up; 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 variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 143/81, BMI 36.0, cardiopulmonary exam stable, feet checked when diabetes present. A: Type 2 diabetes follow-up; 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 variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 142/80, BMI 35.0, cardiopulmonary exam stable, feet checked when diabetes present. A: Type 2 diabetes follow-up; 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 variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 141/79, BMI 34.0, cardiopulmonary exam stable, feet checked when diabetes present. A: Type 2 diabetes follow-up; 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.
Synthetic diabetes monitoring review
Longitudinal synthetic data suggests diabetes with recent monitoring possibly due.
Synthetic CKD surveillance review
Synthetic eGFR/ACR trend suggests CKD surveillance should be reviewed.
Laboratory
Lab panel: HbA1c 7.0%, LDL 3.1 mmol/L, eGFR 52, ACR 5.6. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 6.9%, LDL 3.0 mmol/L, eGFR 51, ACR 5.5. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 6.8%, LDL 2.9 mmol/L, eGFR 50, ACR 5.4. Interpret in clinical context.
Laboratory
Lab panel: HbA1c 6.7%, LDL 2.8 mmol/L, eGFR 49, ACR 5.3. Interpret in clinical context.
Laboratory
Hba1c
7 %
2026-05-05Fasting Glucose
8.4 mmol/L
2026-05-05Ldl Cholesterol
3.1 mmol/L
2026-05-05Egfr
52 mL/min/1.73m2
2026-05-05Albumin Creatinine Ratio
5.6 mg/mmol
2026-05-05Systolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
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 no major interval concerns. O: BP 144/82, BMI 23.0,... | 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 no major interval concerns. O: BP 143/81, BMI 36.0,... | 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 no major interval concerns. O: BP 142/80, BMI 35.0,... | 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 no major interval concerns. O: BP 141/79, BMI 34.0,... | 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 no major interval concerns. O: BP 144/82, BMI 23.0,... | 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 no major interval concerns. O: BP 143/81, BMI 36.0,... | Care element: smoking_status former synthetic-demo | probable | |
alert | Renal function requires ongoing monitoring | Synthetic alert for testing active cohort and review workflows. | |
clinical_flag | Synthetic CKD surveillance review | new | high | synthetic_longitudinal_data | Synthetic eGFR/ACR trend suggests CKD surveillance should be reviewed. | |
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 no major interval concerns. O: BP 144/82, BMI 23.0, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 7.0%, LDL 3.1 mmol/L, eGFR 52, ACR 5.6. Interpret in clinical context. | |
care_element | hba1c | 7.0 | |
care_element | albumin_creatinine_ratio | 5.6 | |
care_element | ldl_cholesterol | 3.1 | |
care_element | bmi | 35.6 | |
care_element | smoking_status | former | |
care_element | systolic_bp | 116 | |
care_element | diastolic_bp | 78 | |
care_element | egfr | 52 | |
care_element | fasting_glucose | 8.4 | |
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 no major interval concerns. O: BP 143/81, BMI 36.0, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 6.9%, LDL 3.0 mmol/L, eGFR 51, ACR 5.5. Interpret in clinical context. | |
care_element | albumin_creatinine_ratio | 5.5 | |
care_element | smoking_status | former | |
care_element | bmi | 34.6 | |
care_element | diastolic_bp | 77 | |
care_element | systolic_bp | 115 | |
care_element | egfr | 51 | |
care_element | ldl_cholesterol | 3.0 | |
care_element | fasting_glucose | 8.3 | |
care_element | hba1c | 6.9 | |
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 no major interval concerns. O: BP 142/80, BMI 35.0, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 6.8%, LDL 2.9 mmol/L, eGFR 50, ACR 5.4. Interpret in clinical context. | |
care_element | bmi | 33.6 | |
care_element | smoking_status | former | |
care_element | systolic_bp | 114 | |
care_element | diastolic_bp | 76 | |
care_element | albumin_creatinine_ratio | 5.4 | |
care_element | egfr | 50 | |
care_element | ldl_cholesterol | 2.9 | |
care_element | fasting_glucose | 8.2 | |
care_element | hba1c | 6.8 | |
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 no major interval concerns. O: BP 141/79, BMI 34.0, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 6.7%, LDL 2.8 mmol/L, eGFR 49, ACR 5.3. Interpret in clinical context. | |
care_element | egfr | 49 | |
care_element | albumin_creatinine_ratio | 5.3 | |
care_element | hba1c | 6.7 | |
care_element | fasting_glucose | 8.1 | |
care_element | ldl_cholesterol | 2.8 | |
care_element | smoking_status | former | |
care_element | bmi | 32.6 | |
care_element | diastolic_bp | 75 | |
care_element | systolic_bp | 113 | |
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 no major interval concerns. O: BP 140/78, BMI 33.0, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 6.6%, LDL 2.7 mmol/L, eGFR 48, ACR 5.2. Interpret in clinical context. | |
care_element | diastolic_bp | 74 | |
care_element | albumin_creatinine_ratio | 5.2 | |
care_element | egfr | 48 | |
care_element | ldl_cholesterol | 2.7 | |
care_element | fasting_glucose | 8.0 | |
care_element | hba1c | 6.6 | |
care_element | smoking_status | former | |
care_element | bmi | 31.6 | |
care_element | systolic_bp | 112 | |
note | SOAP note | S: Patient seen for longitudinal primary care follow-up. Reports variable home glucose readings and medication adherence questions, with no major interval concerns. O: BP 139/77, BMI 32.0, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 8.9%, LDL 2.6 mmol/L, eGFR 47, ACR 5.1. Interpret in clinical context. | |
care_element | hba1c | 8.9 | |
care_element | smoking_status | former | |
care_element | bmi | 30.6 | |
care_element | diastolic_bp | 73 | |
care_element | systolic_bp | 135 | |
care_element | albumin_creatinine_ratio | 5.1 | |
care_element | egfr | 47 | |
care_element | ldl_cholesterol | 2.6 | |
care_element | fasting_glucose | 7.9 | |
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 no major interval concerns. O: BP 138/76, BMI 31.0, cardiopulmonary exam stable, feet checked when diab | |
report | Laboratory | Lab panel: HbA1c 8.8%, LDL 2.5 mmol/L, eGFR 46, ACR 5.0. Interpret in clinical context. | |
care_element | ldl_cholesterol | 2.5 | |
care_element | fasting_glucose | 7.8 | |
care_element | hba1c | 8.8 | |
care_element | diastolic_bp | 72 | |
care_element | bmi | 29.6 | |
care_element | smoking_status | former | |
care_element | albumin_creatinine_ratio | 5.0 | |
care_element | systolic_bp | 134 | |
care_element | egfr | 46 | |
appointment | Chronic disease follow-up | completed | |
appointment | Chronic disease follow-up | completed |
Lab panel: HbA1c 6.6%, LDL 2.7 mmol/L, eGFR 48, ACR 5.2. Interpret in clinical context.
116 mmHg
2026-05-05Diastolic Bp
78 mmHg
2026-05-05Bmi
35.6 kg/m2
2026-05-05Smoking Status
former
2026-05-05Hba1c
6.9 %
2025-04-04Fasting Glucose
8.3 mmol/L
2025-04-04Ldl Cholesterol
3 mmol/L
2025-04-04Egfr
51 mL/min/1.73m2
2025-04-04Albumin Creatinine Ratio
5.5 mg/mmol
2025-04-04Systolic Bp
115 mmHg
2025-04-04Diastolic Bp
77 mmHg
2025-04-04Bmi
34.6 kg/m2
2025-04-04Smoking Status
former
2025-04-04Hba1c
6.8 %
2024-03-03Fasting Glucose
8.2 mmol/L
2024-03-03Ldl Cholesterol
2.9 mmol/L
2024-03-03Egfr
50 mL/min/1.73m2
2024-03-03Albumin Creatinine Ratio
5.4 mg/mmol
2024-03-03Systolic Bp
114 mmHg
2024-03-03Diastolic Bp
76 mmHg
2024-03-03Bmi
33.6 kg/m2
2024-03-03Smoking Status
former
2024-03-03Hba1c
6.7 %
2023-02-02Fasting Glucose
8.1 mmol/L
2023-02-02Ldl Cholesterol
2.8 mmol/L
2023-02-02Egfr
49 mL/min/1.73m2
2023-02-02Albumin Creatinine Ratio
5.3 mg/mmol
2023-02-02Systolic Bp
113 mmHg
2023-02-02Diastolic Bp
75 mmHg
2023-02-02Bmi
32.6 kg/m2
2023-02-02Smoking Status
former
2023-02-02Hba1c
6.6 %
2022-01-01Fasting Glucose
8 mmol/L
2022-01-01Ldl Cholesterol
2.7 mmol/L
2022-01-01Egfr
48 mL/min/1.73m2
2022-01-01Albumin Creatinine Ratio
5.2 mg/mmol
2022-01-01Systolic Bp
112 mmHg
2022-01-01Diastolic Bp
74 mmHg
2022-01-01Bmi
31.6 kg/m2
2022-01-01Smoking Status
former
2022-01-01Hba1c
8.9 %
2021-12-24Fasting Glucose
7.9 mmol/L
2021-12-24Ldl Cholesterol
2.6 mmol/L
2021-12-24Egfr
47 mL/min/1.73m2
2021-12-24Albumin Creatinine Ratio
5.1 mg/mmol
2021-12-24Systolic Bp
135 mmHg
2021-12-24Diastolic Bp
73 mmHg
2021-12-24Bmi
30.6 kg/m2
2021-12-24Smoking Status
former
2021-12-24Hba1c
8.8 %
2020-11-23Fasting Glucose
7.8 mmol/L
2020-11-23Ldl Cholesterol
2.5 mmol/L
2020-11-23Egfr
46 mL/min/1.73m2
2020-11-23Albumin Creatinine Ratio
5 mg/mmol
2020-11-23Systolic Bp
134 mmHg
2020-11-23Diastolic Bp
72 mmHg
2020-11-23Bmi
29.6 kg/m2
2020-11-23Smoking Status
former
2020-11-23