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Population Health
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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: diabetes_prediabetes prediabetes_risk medium in_review Prediabetes range HbA1c Latest HbA1c 6.0% falls in the prediabetes range without a diabetes problem-li...
membership needs review
No review task has been created from this cohort for this patient yet.
Smoking / Lung Screening review cohort
Chart evidence: Flag: frailty_falls recurrent_falls high new Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Care...
Open review tasks
4
New, in review, or accepted tasks
Last visit
2026-02-11
Appointment or derived chart contact
Latest A1c
6 %
2026-03-06
Latest BP
140 mmHg / 77 mmHg
2026-02-23
Extracted signals
0
Optional text signals
Chart volume
28
4 notes, 0 reports
A compact view of what needs attention before opening the full imported record.
Review priority
2
active signal
s
4
0
0
Review these before relying on the imported record clinically.
Review needed
4 open flags
Open clinical review items need status, assignment, or closure.
BP above target
Latest BP is 140 mmHg / 77 mmHg on 2026-02-23.
Active problems
2
Frailty risk
active
Prediabetes
R73.03
active
Active medications
0
No active medications imported.
membership needs review
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.
14, more source rows below
Latest narrative evidence, clipped for scanning.
Recent report headers and excerpts.
No reports imported
Audit view for imported records. Kept collapsed so the working chart remains usable.
PHM saved action
PHM action: RECURRENT_FALLS
status=needs_review | imported | next review=2026-06-09 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
PHM saved action
PHM action: NARRATIVE_OA_WITHOUT_PROBLEM
status=new | imported | next review=2026-07-17 | Review evidence for Narrative OA evidence missing from problem list; confirm appropriateness before contacting patient.
PHM saved action
PHM action: PREDIABETES_RISK
status=new | imported | next review=2026-08-01 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: diabetes_prediabetes prediabetes_risk medium in_review Prediabetes range HbA1c Latest HbA1c 6.0% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Flag: frailty_falls recurrent_falls high new Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | Problem: active: Frailty risk: {"id":"PROB00570","patient_id":"PAT0273","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2022-12-23","source":"problem_list"} | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Flag: frailty_falls recurrent_falls high new Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Care element: smoking_status never smoker form | probable
phm_workflow
PHM action: RECURRENT_FALLS
status=needs_review | imported | next review=2026-06-09 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
phm_workflow
PHM action: NARRATIVE_OA_WITHOUT_PROBLEM
status=new | imported | next review=2026-07-17 | Review evidence for Narrative OA evidence missing from problem list; confirm appropriateness before contacting patient.
phm_workflow
PHM action: PREDIABETES_RISK
status=new | imported | next review=2026-08-01 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient.
clinical_flag
Pneumococcal immunization review
new | medium | active_cohort_automation | Older adult with no pneumococcal immunization evidence in the synthetic chart.
clinical_flag
Influenza immunization recall
completed | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window.
clinical_flag
Recurrent falls risk
new | high | clinical_note | Recent note documents 2 fall(s) in the past year with frailty/gait concerns.
clinical_flag
Narrative OA evidence missing from problem list
new | medium | clinical_note | Clinical note describes osteoarthritis-like hip symptoms but there is no structured OA problem-list entry.
clinical_flag
Prediabetes range HbA1c
in_review | medium | structured_fact | Latest HbA1c 6.0% falls in the prediabetes range without a diabetes problem-list diagnosis.
note
SOAP note
Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed.
note
SOAP note
MSK review: chronic hip pain with morning stiffness and crepitus, consistent with osteoarthritis pattern. Discussed activity modification, strengthening, topical/oral analgesia risks, imaging only if red flags or surgical planning.
appointment
lab follow-up
completed
note
preventive care
HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented.
SOAP note
Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed.
SOAP note
MSK review: chronic hip pain with morning stiffness and crepitus, consistent with osteoarthritis pattern. Discussed activity modification, strengthening, topical/oral analgesia risks, imaging only if red flags or surgical planning.
preventive care
HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented.
SOAP note
Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports no acute concern. Plan: update labs/vitals and arrange follow-up as clinically indicated.
Pneumococcal immunization review
Older adult with no pneumococcal immunization evidence in the synthetic chart.
Influenza immunization recall
No recent influenza immunization evidence within the synthetic seasonal window.
Recurrent falls risk
Recent note documents 2 fall(s) in the past year with frailty/gait concerns.
Narrative OA evidence missing from problem list
Clinical note describes osteoarthritis-like hip symptoms but there is no structured OA problem-list entry.
Prediabetes range HbA1c
Latest HbA1c 6.0% falls in the prediabetes range without a diabetes problem-list diagnosis.
Hba1c
6 %
2026-03-06Diastolic Bp
77 mmHg
2026-02-23Systolic Bp
140 mmHg
2026-02-23Smoking Status
never smoker
2026-02-02Hba1c
6.2 %
2025-05-19Egfr
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: diabetes_prediabetes prediabetes_risk medium in_review Prediabetes range HbA1c Latest HbA1c 6.0% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Flag: frailty_falls recurrent_falls high new Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | Problem: active: Frailty risk: {"id":"PROB00570","patient_id":"PAT0273","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2022-12-23","source":"problem_list"} | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Flag: frailty_falls recurrent_falls high new Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Care element: smoking_status never smoker form | probable | |
phm_workflow | PHM action: RECURRENT_FALLS | status=needs_review | imported | next review=2026-06-09 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: NARRATIVE_OA_WITHOUT_PROBLEM | status=new | imported | next review=2026-07-17 | Review evidence for Narrative OA evidence missing from problem list; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: PREDIABETES_RISK | status=new | imported | next review=2026-08-01 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient. | |
clinical_flag | Pneumococcal immunization review | new | medium | active_cohort_automation | Older adult with no pneumococcal immunization evidence in the synthetic chart. | |
clinical_flag | Influenza immunization recall | completed | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window. | |
clinical_flag | Recurrent falls risk | new | high | clinical_note | Recent note documents 2 fall(s) in the past year with frailty/gait concerns. | |
clinical_flag | Narrative OA evidence missing from problem list | new | medium | clinical_note | Clinical note describes osteoarthritis-like hip symptoms but there is no structured OA problem-list entry. | |
clinical_flag | Prediabetes range HbA1c | in_review | medium | structured_fact | Latest HbA1c 6.0% falls in the prediabetes range without a diabetes problem-list diagnosis. | |
note | SOAP note | Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | |
note | SOAP note | MSK review: chronic hip pain with morning stiffness and crepitus, consistent with osteoarthritis pattern. Discussed activity modification, strengthening, topical/oral analgesia risks, imaging only if red flags or surgical planning. | |
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | lab follow-up | completed | |
care_element | smoking_status | never smoker | |
note | preventive care | HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented. | |
care_element | hba1c | ||
care_element | egfr | ||
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports no acute concern. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
care_element | bmi | ||
appointment | same-day concern | completed | |
care_element | immunization | Influenza vaccine documented | |
care_element | immunization | COVID-19 vaccine documented | |
appointment | medication renewal | completed | |
care_element | hba1c | ||
appointment | medication renewal | booked |
63 mL/min/1.73m2
2025-02-25Bmi
18.6 kg/m2
2025-01-26Immunization
Influenza vaccine documented
2024-08-11Immunization
COVID-19 vaccine documented
2023-11-15Hba1c
6.1 %
2021-08-24