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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: 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: 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
5
New, in review, or accepted tasks
Last visit
2026-03-06
Appointment or derived chart contact
Latest A1c
8.1 %
2026-02-22
Latest BP
138 mmHg / 76 mmHg
2026-04-05
Extracted signals
0
Optional text signals
Chart volume
56
6 notes, 3 reports
A compact view of what needs attention before opening the full imported record.
Review priority
2
active signal
s
5
0
0
Review these before relying on the imported record clinically.
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.
42, 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: INFLUENZA_RECALL_DUE
status=snoozed | imported | next review=2026-06-09 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient.
PHM saved action
PHM action: RECURRENT_FALLS
status=needs_review | imported | outreach=phone 2026-03-24 17:45 | next review=2026-06-09 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
PHM saved action
PHM action: DEMENTIA_CARE_PLAN_DUE
status=in_review | imported | next review=2026-06-16 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient.
PHM saved action
PHM action: UNCONTROLLED_HBA1C
status=needs_review | imported | next review=2026-06-16 | Review evidence for HbA1c above target; 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 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 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. | Clinical note: SOAP note Cognitive follow-up. Family reports stable memory with reminders. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | 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: INFLUENZA_RECALL_DUE
status=snoozed | imported | next review=2026-06-09 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient.
phm_workflow
PHM action: RECURRENT_FALLS
status=needs_review | imported | outreach=phone 2026-03-24 17:45 | next review=2026-06-09 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
phm_workflow
PHM action: DEMENTIA_CARE_PLAN_DUE
status=in_review | imported | next review=2026-06-16 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient.
phm_workflow
PHM action: UNCONTROLLED_HBA1C
status=needs_review | imported | next review=2026-06-16 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient.
clinical_flag
Influenza immunization recall
new | 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
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
Urine ACR overdue
accepted | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
clinical_flag
HbA1c above target
in_review | high | structured_fact | Latest HbA1c 8.1% suggests above-target glycemic control and needs clinician review.
alert
Diabetes control flag: HbA1c above target
Generated from longitudinal lab trend.
note
SOAP note
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.
note
consult
Atrial fibrillation follow-up. Patient reports no chest pain. Plan: continue guideline-oriented risk management and monitor labs.
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.
consult
Atrial fibrillation follow-up. Patient reports no chest pain. Plan: continue guideline-oriented risk management and monitor labs.
SOAP note
Cognitive follow-up. Family reports stable memory with reminders. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
SOAP note
BP reviewed. Home readings mostly controlled. Reviewed sodium, adherence, and medication tolerance.
Screening
colonoscopy complete
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
Consult
Consult follow-up for Atrial fibrillation. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
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.
Dementia care plan review
Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed.
Urine ACR overdue
Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
HbA1c above target
Latest HbA1c 8.1% suggests above-target glycemic control and needs clinician review.
Review needed
5 open flags
Open clinical review items need status, assignment, or closure.
A1c above review threshold
Latest HbA1c is 8.1 % on 2026-02-22.
Active problems
5
Frailty risk
active
Alzheimer-type dementia
F03
active
Atrial fibrillation
I48
active
Essential hypertension
I10
active
Type 2 diabetes mellitus
E11
active
Active medications
6
ASA 81 mg
81 mg daily
Rosuvastatin
20 mg daily
Candesartan
8 mg daily
Ramipril
5 mg daily
Metformin XR
Egfr
68 mL/min/1.73m2
2026-05-28Diastolic Bp
76 mmHg
2026-04-05Systolic Bp
138 mmHg
2026-04-05Fasting Glucose
9.5 mmol/L
2026-03-19Cancer Screening
colonoscopy complete
2026-03-16Hba1c
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 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 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. | Clinical note: SOAP note Cognitive follow-up. Family reports stable memory with reminders. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | 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: INFLUENZA_RECALL_DUE | status=snoozed | imported | next review=2026-06-09 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: RECURRENT_FALLS | status=needs_review | imported | outreach=phone 2026-03-24 17:45 | next review=2026-06-09 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: DEMENTIA_CARE_PLAN_DUE | status=in_review | imported | next review=2026-06-16 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: UNCONTROLLED_HBA1C | status=needs_review | imported | next review=2026-06-16 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient. | |
clinical_flag | Influenza immunization recall | new | 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 | 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 | Urine ACR overdue | accepted | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window. | |
clinical_flag | HbA1c above target | in_review | high | structured_fact | Latest HbA1c 8.1% suggests above-target glycemic control and needs clinician review. | |
alert | Diabetes control flag: HbA1c above target | Generated from longitudinal lab trend. | |
care_element | egfr | ||
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. | |
note | consult | Atrial fibrillation follow-up. Patient reports no chest pain. Plan: continue guideline-oriented risk management and monitor labs. | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
note | SOAP note | Cognitive follow-up. Family reports stable memory with reminders. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | |
care_element | fasting_glucose | ||
report | Screening | colonoscopy complete | |
care_element | cancer_screening | colonoscopy complete | |
appointment | same-day concern | completed | |
care_element | hba1c | ||
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
care_element | immunization | COVID-19 vaccine documented | |
care_element | ldl_cholesterol | ||
care_element | bmi | ||
note | SOAP note | BP reviewed. Home readings mostly controlled. Reviewed sodium, adherence, and medication tolerance. | |
appointment | chronic disease review | no_show | |
note | SOAP note | Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed. | |
care_element | smoking_status | never smoker | |
care_element | hba1c | ||
care_element | ldl_cholesterol | ||
care_element | fasting_glucose | ||
care_element | ldl_cholesterol | ||
report | Consult | Consult follow-up for Atrial fibrillation. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed. | |
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. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | immunization | Influenza vaccine documented | |
appointment | medication renewal | completed | |
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | fasting_glucose | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
appointment | periodic health review | cancelled | |
care_element | immunization | Pneumococcal vaccine documented | |
appointment | same-day concern | completed | |
care_element | hba1c | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | chronic disease review | completed |
1000 mg daily
8.1 %
2026-02-22Immunization
COVID-19 vaccine documented
2026-02-02Ldl Cholesterol
2.9 mmol/L
2026-01-24Bmi
21.8 kg/m2
2025-12-20Smoking Status
never smoker
2025-09-30Hba1c
7.2 %
2025-06-10Ldl Cholesterol
3.7 mmol/L
2025-01-25Fasting Glucose
9.7 mmol/L
2024-12-19Ldl Cholesterol
4.1 mmol/L
2024-11-19Diastolic Bp
72 mmHg
2024-06-25Systolic Bp
136 mmHg
2024-06-25Immunization
Influenza vaccine documented
2024-04-13Hba1c
8.1 %
2023-06-24Diastolic Bp
86 mmHg
2023-05-03Systolic Bp
132 mmHg
2023-05-03Fasting Glucose
9.2 mmol/L
2022-12-02Diastolic Bp
70 mmHg
2022-11-20Systolic Bp
124 mmHg
2022-11-20Ldl Cholesterol
3.7 mmol/L
2022-07-11Hba1c
7.8 %
2022-06-13Immunization
Pneumococcal vaccine documented
2022-03-23Hba1c
7.8 %
2021-06-11Diastolic Bp
82 mmHg
2021-01-08Systolic Bp
136 mmHg
2021-01-08