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Accepted chart labels
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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.
1, current
Smoking / Lung Screening review cohort
Chart evidence: Care element: smoking_status former smoker form
membership needs review
No review task has been created from this cohort for this patient yet.
Open review tasks
4
New, in review, or accepted tasks
Last visit
2026-04-29
Appointment or derived chart contact
Latest A1c
9.1 %
2026-01-14
Latest BP
151 mmHg / 77 mmHg
2026-05-01
Extracted signals
0
Optional text signals
Chart volume
54
6 notes, 3 reports
A compact view of what needs attention before opening the full imported record.
Review priority
3
active signal
s
4
0
0
Review these before relying on the imported record clinically.
AI-CDS actions selected from Flags & Tasks. These stay visible on the chart for follow-up.
0, selected
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40, more source rows below
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PHM saved action
PHM action: EYE_EXAM_OVERDUE
status=needs_review | imported | outreach=sms 2026-06-02 14:00 | next review=2026-07-17 | Review evidence for Eye exam evidence missing or overdue; confirm appropriateness before contacting patient.
PHM saved action
PHM action: DIABETES_ACR_OVERDUE
status=needs_review | imported | next review=2026-07-17 | Review evidence for Urine ACR overdue; confirm appropriateness before contacting patient.
ai_cds_review
AI-CDS review: Polypharmacy medication review
Summary - Suggested for clinician review: polypharmacy flag with 8 active medications - Medication reconciliation and deprescribing opportunities should be reviewed - Higher-risk context: diabetes, CKD stage 2 with albuminuria, hypertension, prior TIA/stroke Signal: medication_review / polypharmacy_review / medium / confirmed Chart evidence - 8 active medications listed: rosuvastatin, empagliflozin, celecoxib, amlodipine, metformin, apixaban, semaglutide, atorvastatin - Active problems include E11 type 2 diabetes, N18 CKD stage 2 with albuminuria, I10 hypertension, and Z86.73 history of TIA/stroke - Recent BP 151/77 mmHg on 2026-05-01; prior home readings above target noted in 2025-10-14 note - HbA1c 9.1% on 2026-01-14; prior ACR 29.3 and 38.6 mg/mmol in March 2025 - Celecoxib is active while patient is on apixaban and has CKD/albuminuria Guidance alignment - Medication safety review is supported by Ontario Health Quality Standard: Medication Safety [1] Recommended actions - Reconcile current medication list against actual use, dose, and indication - Review for duplicate therapy and deprescribing opportunities, especially dual statin listing (rosuvastatin and atorvastatin) - Check bleeding/renal risk with celecoxib plus apixaban and CKD/albuminuria - Confirm monitoring plan for BP, glycemia, renal function, and medication tolerance Cautions - Do not stop anticoagulation or cardiometabolic therapy without clinician review - NSAID use may increase renal and bleeding risk in this context - Recent eye exam and urine ACR status are not documented in the supplied chart window References [1] Medication Safety: https://ontariohealth.ca/content/dam/ontariohealth/documents/filter-list/qs/qs-medication-safety-quality-standard-en.pdf Would you like a focused medication reconciliation summary highlighting duplicates, interaction risks, and deprescribing candidates?
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status former smoker form | probable
phm_workflow
PHM action: EYE_EXAM_OVERDUE
status=needs_review | imported | outreach=sms 2026-06-02 14:00 | next review=2026-07-17 | Review evidence for Eye exam evidence missing or overdue; confirm appropriateness before contacting patient.
phm_workflow
PHM action: DIABETES_ACR_OVERDUE
status=needs_review | imported | next review=2026-07-17 | Review evidence for Urine ACR overdue; confirm appropriateness before contacting patient.
clinical_flag
Polypharmacy medication review
accepted | medium | structured_fact | 8 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed.
clinical_flag
Eye exam evidence missing or overdue
new | medium | active_cohort_automation | Diabetic eye screening risk is documented but no recent eye exam report is present in the synthetic chart.
clinical_flag
Urine ACR overdue
new | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
clinical_flag
HbA1c above target
accepted | high | structured_fact | Latest HbA1c 9.1% suggests above-target glycemic control and needs clinician review.
alert
Diabetes control flag: HbA1c above target
Generated from longitudinal lab trend.
note
SOAP note
Pain follow-up for chronic low back pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 6/10.
appointment
periodic health review
completed
note
SOAP note
Mental health review. PHQ-9 11, GAD-7 6. Sleep adequate. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
report
Laboratory
Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring.
note
SOAP note
BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance.
SOAP note
Pain follow-up for chronic low back pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 6/10.
SOAP note
Mental health review. PHQ-9 11, GAD-7 6. Sleep adequate. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
SOAP note
BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance.
SOAP note
Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports improving symptoms. Plan: update labs/vitals and arrange follow-up as clinically indicated.
Laboratory
Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring.
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
Consult
Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
Polypharmacy medication review
AI-CDS saved
8 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed.
Eye exam evidence missing or overdue
Diabetic eye screening risk is documented but no recent eye exam report is present in the synthetic chart.
Urine ACR overdue
Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
HbA1c above target
Latest HbA1c 9.1% suggests above-target glycemic control and needs clinician review.
Review needed
4 open flags
Open clinical review items need status, assignment, or closure.
A1c above review threshold
Latest HbA1c is 9.1 % on 2026-01-14.
BP above target
Latest BP is 151 mmHg / 77 mmHg on 2026-05-01.
Active problems
7
Diabetic eye screening risk
active
Chronic low back pain
active
PTSD
active
Chronic kidney disease stage 2 with albuminuria
N18
active
History of TIA/stroke
Z86.73
active
Active medications
8
Celecoxib
100 mg BID PRN
Rosuvastatin
20 mg daily
Atorvastatin
40 mg daily
Apixaban
5 mg BID
Amlodipine
Diastolic Bp
77 mmHg
2026-05-01Systolic Bp
151 mmHg
2026-05-01Egfr
69 mL/min/1.73m2
2026-04-11Fasting Glucose
8.3 mmol/L
2026-04-03Ldl Cholesterol
3.7 mmol/L
2026-02-20Hba1c
Date | Type | Title | Detail |
|---|---|---|---|
ai_cds_review | AI-CDS review: Polypharmacy medication review | Summary - Suggested for clinician review: polypharmacy flag with 8 active medications - Medication reconciliation and deprescribing opportunities should be reviewed - Higher-risk context: diabetes, CKD stage 2 with albuminuria, hypertension, prior TIA/stroke Signal: medication_review / polypharmacy_review / medium / confirmed Chart evidence - 8 active medications listed: rosuvastatin, empagliflozin, celecoxib, amlodipine, metformin, apixaban, semaglutide, atorvastatin - Active problems include E11 type 2 diabetes, N18 CKD stage 2 with albuminuria, I10 hypertension, and Z86.73 history of TIA/stroke - Recent BP 151/77 mmHg on 2026-05-01; prior home readings above target noted in 2025-10-14 note - HbA1c 9.1% on 2026-01-14; prior ACR 29.3 and 38.6 mg/mmol in March 2025 - Celecoxib is active while patient is on apixaban and has CKD/albuminuria Guidance alignment - Medication safety review is supported by Ontario Health Quality Standard: Medication Safety [1] Recommended actions - Reconcile current medication list against actual use, dose, and indication - Review for duplicate therapy and deprescribing opportunities, especially dual statin listing (rosuvastatin and atorvastatin) - Check bleeding/renal risk with celecoxib plus apixaban and CKD/albuminuria - Confirm monitoring plan for BP, glycemia, renal function, and medication tolerance Cautions - Do not stop anticoagulation or cardiometabolic therapy without clinician review - NSAID use may increase renal and bleeding risk in this context - Recent eye exam and urine ACR status are not documented in the supplied chart window References [1] Medication Safety: https://ontariohealth.ca/content/dam/ontariohealth/documents/filter-list/qs/qs-medication-safety-quality-standard-en.pdf Would you like a focused medication reconciliation summary highlighting duplicates, interaction risks, and deprescribing candidates? | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status former smoker form | probable | |
phm_workflow | PHM action: EYE_EXAM_OVERDUE | status=needs_review | imported | outreach=sms 2026-06-02 14:00 | next review=2026-07-17 | Review evidence for Eye exam evidence missing or overdue; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: DIABETES_ACR_OVERDUE | status=needs_review | imported | next review=2026-07-17 | Review evidence for Urine ACR overdue; confirm appropriateness before contacting patient. | |
clinical_flag | Polypharmacy medication review | accepted | medium | structured_fact | 8 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed. | |
clinical_flag | Eye exam evidence missing or overdue | new | medium | active_cohort_automation | Diabetic eye screening risk is documented but no recent eye exam report is present in the synthetic chart. | |
clinical_flag | Urine ACR overdue | new | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window. | |
clinical_flag | HbA1c above target | accepted | high | structured_fact | Latest HbA1c 9.1% suggests above-target glycemic control and needs clinician review. | |
alert | Diabetes control flag: HbA1c above target | Generated from longitudinal lab trend. | |
note | SOAP note | Pain follow-up for chronic low back pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 6/10. | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | periodic health review | completed | |
care_element | egfr | ||
care_element | fasting_glucose | ||
note | SOAP note | Mental health review. PHQ-9 11, GAD-7 6. Sleep adequate. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | |
care_element | ldl_cholesterol | ||
report | Laboratory | Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring. | |
care_element | hba1c | ||
care_element | fasting_glucose | ||
care_element | ldl_cholesterol | ||
note | SOAP note | BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | |
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports improving symptoms. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
note | SOAP note | T2DM review. Home glucose pattern often elevated fasting. Discussed nutrition, exercise, foot care, and medication adherence. Plan: repeat HbA1c and review cardiovascular/renal risk. | |
note | consult | History of TIA/stroke follow-up. Patient reports leg discomfort with walking. Plan: continue guideline-oriented risk management and monitor labs. | |
care_element | bmi | ||
care_element | hba1c | ||
appointment | chronic disease review | completed | |
care_element | albumin_creatinine_ratio | ||
care_element | albumin_creatinine_ratio | ||
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
care_element | smoking_status | former smoker | |
care_element | fasting_glucose | ||
report | Consult | Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed. | |
care_element | egfr | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | ldl_cholesterol | ||
appointment | periodic health review | completed | |
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | hba1c | ||
care_element | ldl_cholesterol | ||
appointment | periodic health review | completed | |
care_element | egfr | ||
care_element | hba1c | ||
appointment | periodic health review | completed | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | medication renewal | completed |
5 mg daily
9.1 %
2026-01-14Fasting Glucose
10.7 mmol/L
2025-11-16Ldl Cholesterol
3.4 mmol/L
2025-10-22Bmi
29.1 kg/m2
2025-05-05Hba1c
8.7 %
2025-03-14Albumin Creatinine Ratio
29.3 mg/mmol
2025-03-08Albumin Creatinine Ratio
38.6 mg/mmol
2025-03-07Smoking Status
former smoker
2024-10-30Fasting Glucose
9.1 mmol/L
2024-09-27Egfr
67 mL/min/1.73m2
2024-04-28Diastolic Bp
82 mmHg
2024-04-27Systolic Bp
130 mmHg
2024-04-27Ldl Cholesterol
1.3 mmol/L
2024-04-22Hba1c
8.3 %
2024-01-23Diastolic Bp
76 mmHg
2023-08-19Systolic Bp
145 mmHg
2023-08-19Hba1c
8.5 %
2023-05-12Ldl Cholesterol
3.7 mmol/L
2023-05-01Egfr
70 mL/min/1.73m2
2022-12-17Hba1c
7.6 %
2022-07-03Diastolic Bp
71 mmHg
2022-03-08Systolic Bp
134 mmHg
2022-03-08Hba1c
8.7 %
2021-10-06Diastolic Bp
84 mmHg
2021-03-25Systolic Bp
127 mmHg
2021-03-25