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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
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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 new Prediabetes range HbA1c Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list dia...
membership needs review
No review task has been created from this cohort for this patient yet.
Smoking / Lung Screening review cohort
Chart evidence: Flag: copd copd_recurrent_exacerbation high new Recurrent COPD exacerbation pattern Multiple COPD-related visits/exacerbation language identified within the recent...
Open review tasks
3
New, in review, or accepted tasks
Last visit
2026-04-18
Appointment or derived chart contact
Latest A1c
5.8 %
2025-10-07
Latest BP
149 mmHg / 87 mmHg
2026-03-09
Extracted signals
0
Optional text signals
Chart volume
40
7 notes, 1 reports
A compact view of what needs attention before opening the full imported record.
Review priority
2
active signal
s
3
0
0
Review these before relying on the imported record clinically.
Review needed
3 open flags
Open clinical review items need status, assignment, or closure.
BP above target
Latest BP is 149 mmHg / 87 mmHg on 2026-03-09.
Active problems
3
Chronic neck pain
active
Chronic obstructive pulmonary disease
J44.9
active
Essential hypertension
I10
active
Active medications
5
Duloxetine
30 mg daily
Tiotropium inhaler
18 mcg daily
Salbutamol inhaler
100 mcg 1-2 puffs q4h PRN
Hydrochlorothiazide
12.5 mg daily
Ramipril
5 mg daily
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.
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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.
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26, 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: AGE_ELIGIBLE_SCREENING_MISSING
status=needs_review | imported | outreach=phone 2026-04-27 10:40 | next review=2026-06-23 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
PHM saved action
PHM action: COPD_RECURRENT_EXACERBATION
status=in_review | imported | outreach=portal 2026-04-02 11:30 | next review=2026-06-23 | Review evidence for Recurrent COPD exacerbation pattern; confirm appropriateness before contacting patient.
PHM saved action
PHM action: PREDIABETES_RISK
status=new | imported | outreach=email 2026-05-15 12:15 | next review=2026-06-16 | 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 new Prediabetes range HbA1c Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Clinical note: SOAP note BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Flag: copd copd_recurrent_exacerbation high new Recurrent COPD exacerbation pattern Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period. clinical_note | Care element: smoking_status former smoker form | probable
phm_workflow
PHM action: AGE_ELIGIBLE_SCREENING_MISSING
status=needs_review | imported | outreach=phone 2026-04-27 10:40 | next review=2026-06-23 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
phm_workflow
PHM action: COPD_RECURRENT_EXACERBATION
status=in_review | imported | outreach=portal 2026-04-02 11:30 | next review=2026-06-23 | Review evidence for Recurrent COPD exacerbation pattern; confirm appropriateness before contacting patient.
phm_workflow
PHM action: PREDIABETES_RISK
status=new | imported | outreach=email 2026-05-15 12:15 | next review=2026-06-16 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient.
clinical_flag
Age-eligible screening missing
new | medium | clinical_note | Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present.
clinical_flag
Recurrent COPD exacerbation pattern
new | high | clinical_note | Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period.
clinical_flag
Prediabetes range HbA1c
new | medium | structured_fact | Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis.
appointment
periodic health review
completed
note
SOAP note
COPD review. Symptoms include stable exertional dyspnea. Inhaler technique reviewed. Exacerbation risk discussed.
note
SOAP note
BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance.
note
SOAP note
COPD review. Symptoms include stable exertional dyspnea. Inhaler technique reviewed. Exacerbation risk discussed.
note
preventive care
Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records.
note
SOAP note
Pain follow-up for chronic neck pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 6/10.
SOAP note
COPD review. Symptoms include stable exertional dyspnea. Inhaler technique reviewed. Exacerbation risk discussed.
SOAP note
BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance.
SOAP note
COPD review. Symptoms include stable exertional dyspnea. Inhaler technique reviewed. Exacerbation risk discussed.
preventive care
Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records.
Laboratory
Spirometry: obstructive pattern compatible with COPD; post-bronchodilator values documented in scanned pulmonary function report.
Age-eligible screening missing
Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present.
Recurrent COPD exacerbation pattern
Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period.
Prediabetes range HbA1c
Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis.
Smoking Status
former smoker
2026-03-20Diastolic Bp
87 mmHg
2026-03-09Systolic Bp
149 mmHg
2026-03-09Egfr
75 mL/min/1.73m2
2026-01-22Bmi
16 kg/m2
2025-11-19Hba1c
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: diabetes_prediabetes prediabetes_risk medium new Prediabetes range HbA1c Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Clinical note: SOAP note BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Flag: copd copd_recurrent_exacerbation high new Recurrent COPD exacerbation pattern Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period. clinical_note | Care element: smoking_status former smoker form | probable | |
phm_workflow | PHM action: AGE_ELIGIBLE_SCREENING_MISSING | status=needs_review | imported | outreach=phone 2026-04-27 10:40 | next review=2026-06-23 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: COPD_RECURRENT_EXACERBATION | status=in_review | imported | outreach=portal 2026-04-02 11:30 | next review=2026-06-23 | Review evidence for Recurrent COPD exacerbation pattern; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: PREDIABETES_RISK | status=new | imported | outreach=email 2026-05-15 12:15 | next review=2026-06-16 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient. | |
clinical_flag | Age-eligible screening missing | new | medium | clinical_note | Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present. | |
clinical_flag | Recurrent COPD exacerbation pattern | new | high | clinical_note | Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period. | |
clinical_flag | Prediabetes range HbA1c | new | medium | structured_fact | Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis. | |
appointment | periodic health review | completed | |
note | SOAP note | COPD review. Symptoms include stable exertional dyspnea. Inhaler technique reviewed. Exacerbation risk discussed. | |
care_element | smoking_status | former smoker | |
note | SOAP note | BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | egfr | ||
note | SOAP note | COPD review. Symptoms include stable exertional dyspnea. Inhaler technique reviewed. Exacerbation risk discussed. | |
care_element | bmi | ||
note | preventive care | Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records. | |
care_element | hba1c | ||
care_element | immunization | COVID-19 vaccine documented | |
note | SOAP note | Pain follow-up for chronic neck pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 6/10. | |
care_element | immunization | Influenza vaccine documented | |
report | Laboratory | Spirometry: obstructive pattern compatible with COPD; post-bronchodilator values documented in scanned pulmonary function report. | |
note | preventive care | HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports stable function. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
appointment | periodic health review | completed | |
care_element | hba1c | ||
appointment | same-day concern | completed | |
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | lab follow-up | completed | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | hba1c | ||
appointment | chronic disease review | cancelled |
5.8 %
2025-10-07Immunization
COVID-19 vaccine documented
2025-09-05Immunization
Influenza vaccine documented
2025-08-06Diastolic Bp
86 mmHg
2025-05-03Systolic Bp
137 mmHg
2025-05-03Hba1c
6.4 %
2024-06-19Hba1c
6.3 %
2023-05-22Diastolic Bp
79 mmHg
2023-05-07Systolic Bp
128 mmHg
2023-05-07Diastolic Bp
62 mmHg
2022-04-09Systolic Bp
123 mmHg
2022-04-09Diastolic Bp
81 mmHg
2021-01-26Systolic Bp
146 mmHg
2021-01-26Hba1c
6.4 %
2021-01-14