DocChart
Population Health
Patient panel
Loading the selected patient panel and chart summaries.
Switching panel
Preparing patient rows, flags, problems, medications, and last visit summaries.
Panel size
...
Loading patient records
With open flags
...
Loading review signals
With recent visit
...
Loading visit dates
Accepted chart labels
Human-confirmed labels that stay on the chart after a cohort membership is accepted.
0, active
No accepted chart labels yet. Cohort memberships and review tasks still appear below before anything is accepted.
Cohort memberships
Patient-list membership from saved cohort runs. These are source lists, not task status or accepted chart labels.
2, current
Frailty / Falls review cohort
Chart evidence: Flag: dementia dementia_care_plan_due medium new Dementia care plan review Cognitive disorder documented; care plan, caregiver supports, medication safety, and adv...
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 never smoker form
membership needs review
Open review tasks
2
New, in review, or accepted tasks
Last visit
2026-02-08
Appointment or derived chart contact
Latest A1c
7.7 %
2026-03-10
Latest BP
132 mmHg / 81 mmHg
2026-04-12
Extracted signals
0
Optional text signals
Chart volume
53
7 notes, 3 reports
A compact view of what needs attention before opening the full imported record.
Review priority
1
active signal
2
0
0
Review these before relying on the imported record clinically.
No review task has been created from this cohort for this patient yet.
AI-CDS actions selected from Flags & Tasks. These stay visible on the chart for follow-up.
0, selected
No selected follow-up actions
Select AI-CDS actions from Flags & Tasks to keep them visible on this chart.
Saved population-health queue work for this patient: calls, recalls, flags, snoozes, exclusions, and completions.
Optional text-derived evidence extracted beside the imported chart. Each signal stays traceable to source text.
No extracted signals for this patient
Reprocess an import with text enrichment to attach suggested evidence to this patient record.
Most recent values are summarized here so the timeline can stay readable.
Recent chart, workflow, AI, cohort, and audit events shown in the user's local time.
39, more source rows below
Latest narrative evidence, clipped for scanning.
Recent report headers and excerpts.
Audit view for imported records. Kept collapsed so the working chart remains usable.
PHM saved action
PHM action: FALLS_REVIEW_DUE
status=new | imported | outreach=phone 2026-03-12 08:45 | next review=2026-06-16 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient.
PHM saved action
PHM action: DEMENTIA_CARE_PLAN_DUE
status=in_review | imported | next review=2026-07-02 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: dementia dementia_care_plan_due medium new Dementia care plan review Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. clinical_note | Flag: frailty_falls falls_review_due medium accepted Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_note | Flag: chronic_pain_opioids opioid_monitoring_due high dismissed Opioid monitoring review due Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen document... | Clinical note: SOAP note BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status never smoker form | probable
phm_workflow
PHM action: FALLS_REVIEW_DUE
status=new | imported | outreach=phone 2026-03-12 08:45 | next review=2026-06-16 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient.
phm_workflow
PHM action: DEMENTIA_CARE_PLAN_DUE
status=in_review | imported | next review=2026-07-02 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient.
clinical_flag
Possible duplicate ACE inhibitor therapy
completed | high | structured_fact | Two ACE inhibitors appear active in the synthetic medication list and require reconciliation.
clinical_flag
Falls risk review due
accepted | medium | clinical_note | Recent note documents 1 fall(s) in the past year with frailty/gait concerns.
clinical_flag
Opioid monitoring review due
dismissed | high | structured_fact | Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation.
clinical_flag
Dementia care plan review
new | medium | clinical_note | Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed.
clinical_flag
Reduced eGFR requires review
dismissed | high | structured_fact | Latest eGFR 29.0 mL/min/1.73m2 requires medication and renal-risk review.
note
SOAP note
BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance.
note
SOAP note
Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed.
appointment
medication renewal
completed
note
SOAP note
Cognitive follow-up. Family reports missed bills. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
note
consult
Coronary artery disease follow-up. Patient reports palpitations resolved. Plan: continue guideline-oriented risk management and monitor labs.
SOAP note
BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance.
SOAP note
Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed.
SOAP note
Cognitive follow-up. Family reports missed bills. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
consult
Coronary artery disease follow-up. Patient reports palpitations resolved. Plan: continue guideline-oriented risk management and monitor labs.
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
Laboratory
Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring.
Consult
Consult follow-up for Coronary artery disease. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
Possible duplicate ACE inhibitor therapy
Two ACE inhibitors appear active in the synthetic medication list and require reconciliation.
Falls risk review due
Recent note documents 1 fall(s) in the past year with frailty/gait concerns.
Opioid monitoring review due
Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation.
Dementia care plan review
Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed.
Reduced eGFR requires review
Latest eGFR 29.0 mL/min/1.73m2 requires medication and renal-risk review.
Review needed
2 open flags
Open clinical review items need status, assignment, or closure.
Active problems
7
Frailty risk
active
Chronic neuropathic pain
active
Alzheimer-type dementia
F03
active
Chronic kidney disease stage 4
N18
active
Coronary artery disease
I25.10
active
Active medications
8
Perindopril
4 mg daily
Ramipril
5 mg daily
Oxycodone/acetaminophen
5/325 mg q6h PRN
Hydromorphone
1 mg q6h PRN
ASA 81 mg
Albumin Creatinine Ratio
11.9 mg/mmol
2026-05-18Ldl Cholesterol
4.1 mmol/L
2026-04-13Diastolic Bp
81 mmHg
2026-04-12Systolic Bp
132 mmHg
2026-04-12Egfr
95 mL/min/1.73m2
2026-03-28Hba1c
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: dementia dementia_care_plan_due medium new Dementia care plan review Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. clinical_note | Flag: frailty_falls falls_review_due medium accepted Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_note | Flag: chronic_pain_opioids opioid_monitoring_due high dismissed Opioid monitoring review due Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen document... | Clinical note: SOAP note BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status never smoker form | probable | |
phm_workflow | PHM action: FALLS_REVIEW_DUE | status=new | imported | outreach=phone 2026-03-12 08:45 | next review=2026-06-16 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: DEMENTIA_CARE_PLAN_DUE | status=in_review | imported | next review=2026-07-02 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient. | |
clinical_flag | Possible duplicate ACE inhibitor therapy | completed | high | structured_fact | Two ACE inhibitors appear active in the synthetic medication list and require reconciliation. | |
clinical_flag | Falls risk review due | accepted | medium | clinical_note | Recent note documents 1 fall(s) in the past year with frailty/gait concerns. | |
clinical_flag | Opioid monitoring review due | dismissed | high | structured_fact | Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation. | |
clinical_flag | Dementia care plan review | new | medium | clinical_note | Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. | |
clinical_flag | Reduced eGFR requires review | dismissed | high | structured_fact | Latest eGFR 29.0 mL/min/1.73m2 requires medication and renal-risk review. | |
care_element | albumin_creatinine_ratio | ||
note | SOAP note | BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | |
care_element | ldl_cholesterol | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | egfr | ||
note | SOAP note | Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | |
care_element | hba1c | ||
appointment | medication renewal | completed | |
care_element | smoking_status | never smoker | |
note | SOAP note | Cognitive follow-up. Family reports missed bills. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | |
note | consult | Coronary artery disease follow-up. Patient reports palpitations resolved. Plan: continue guideline-oriented risk management and monitor labs. | |
note | SOAP note | Pain follow-up for chronic neuropathic pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 8/10. | |
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports variable energy. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
note | SOAP note | T2DM review. Home glucose pattern limited due to missed checks. Discussed nutrition, exercise, foot care, and medication adherence. Plan: repeat HbA1c and review cardiovascular/renal risk. | |
care_element | hba1c | ||
report | Laboratory | Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring. | |
care_element | albumin_creatinine_ratio | ||
care_element | bmi | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | fasting_glucose | ||
report | Consult | Consult follow-up for Coronary artery disease. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed. | |
care_element | ldl_cholesterol | ||
care_element | egfr | ||
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | hba1c | ||
care_element | egfr | ||
care_element | ldl_cholesterol | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | same-day concern | completed | |
care_element | hba1c | ||
care_element | egfr | ||
care_element | hba1c | ||
care_element | egfr | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | medication renewal | completed |
81 mg daily
7.7 %
2026-03-10Smoking Status
never smoker
2025-12-25Hba1c
7.6 %
2025-07-05Albumin Creatinine Ratio
33.8 mg/mmol
2025-05-11Bmi
35.9 kg/m2
2025-05-03Diastolic Bp
68 mmHg
2025-04-05Systolic Bp
135 mmHg
2025-04-05Fasting Glucose
8.1 mmol/L
2025-03-11Ldl Cholesterol
4.1 mmol/L
2024-12-27Egfr
29 mL/min/1.73m2
2024-12-16Hba1c
7 %
2024-08-05Diastolic Bp
76 mmHg
2024-03-26Systolic Bp
143 mmHg
2024-03-26Diastolic Bp
89 mmHg
2023-07-14Systolic Bp
123 mmHg
2023-07-14Hba1c
7.3 %
2023-05-19Egfr
21 mL/min/1.73m2
2023-05-17Ldl Cholesterol
1.7 mmol/L
2023-03-20Diastolic Bp
86 mmHg
2022-11-23Systolic Bp
140 mmHg
2022-11-23Hba1c
7.4 %
2022-07-04Egfr
26 mL/min/1.73m2
2022-01-26Hba1c
6.9 %
2021-12-10Egfr
24 mL/min/1.73m2
2021-08-12Diastolic Bp
72 mmHg
2021-06-23Systolic Bp
138 mmHg
2021-06-23