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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: frailty_falls falls_review_due medium in_review Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_n...
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 not documented form
membership needs review
Open review tasks
3
New, in review, or accepted tasks
Last visit
2026-04-18
Appointment or derived chart contact
Latest A1c
No A1c
Missing structured value
Latest BP
145 mmHg / 83 mmHg
2026-05-20
Extracted signals
0
Optional text signals
Chart volume
36
3 notes, 2 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 145 mmHg / 83 mmHg on 2026-05-20.
Active problems
3
Frailty risk
active
Chronic kidney disease stage 3b
N18
active
Essential hypertension
I10
active
Active medications
3
Hydrochlorothiazide
12.5 mg daily
Amlodipine
5 mg daily
Candesartan
8 mg daily
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.
22, 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=outreach_done | imported | next review=2026-07-02 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient.
PHM saved action
PHM action: CKD_LOW_EGFR_REVIEW
status=new | imported | next review=2026-07-17 | Review evidence for Reduced eGFR requires review; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: frailty_falls falls_review_due medium in_review Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed. | Clinical note: SOAP note BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | Problem: active: Frailty risk: {"id":"PROB00301","patient_id":"PAT0147","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2022-04-08","source":"problem_list"} | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status not documented form | probable
phm_workflow
PHM action: INFLUENZA_RECALL_DUE
status=outreach_done | imported | next review=2026-07-02 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient.
phm_workflow
PHM action: CKD_LOW_EGFR_REVIEW
status=new | imported | next review=2026-07-17 | Review evidence for Reduced eGFR requires review; 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
Falls risk review due
in_review | medium | clinical_note | Recent note documents 1 fall(s) in the past year with frailty/gait concerns.
clinical_flag
Reduced eGFR requires review
new | medium | structured_fact | Latest eGFR 35.0 mL/min/1.73m2 requires medication and renal-risk review.
clinical_flag
Repeated BP above target
completed | high | structured_fact | Two recent BP readings are above target: 142/84 and 145/83 mmHg.
note
SOAP note
Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed.
note
SOAP note
BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance.
appointment
lab follow-up
completed
note
SOAP note
Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports recent family stress. Plan: update labs/vitals and arrange follow-up as clinically indicated.
report
Screening
FIT negative
report
Laboratory
Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring.
SOAP note
Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed.
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 recent family stress. Plan: update labs/vitals and arrange follow-up as clinically indicated.
Screening
FIT negative
Laboratory
Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring.
Influenza immunization recall
No recent influenza immunization evidence within the synthetic seasonal window.
Falls risk review due
Recent note documents 1 fall(s) in the past year with frailty/gait concerns.
Reduced eGFR requires review
Latest eGFR 35.0 mL/min/1.73m2 requires medication and renal-risk review.
Repeated BP above target
Two recent BP readings are above target: 142/84 and 145/83 mmHg.
Diastolic Bp
83 mmHg
2026-05-20Systolic Bp
145 mmHg
2026-05-20Egfr
35 mL/min/1.73m2
2026-05-15Cancer Screening
FIT negative
2025-12-15Immunization
COVID-19 vaccine documented
2025-09-05Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: frailty_falls falls_review_due medium in_review Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed. | Clinical note: SOAP note BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | Problem: active: Frailty risk: {"id":"PROB00301","patient_id":"PAT0147","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2022-04-08","source":"problem_list"} | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status not documented form | probable | |
phm_workflow | PHM action: INFLUENZA_RECALL_DUE | status=outreach_done | imported | next review=2026-07-02 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: CKD_LOW_EGFR_REVIEW | status=new | imported | next review=2026-07-17 | Review evidence for Reduced eGFR requires review; 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 | Falls risk review due | in_review | medium | clinical_note | Recent note documents 1 fall(s) in the past year with frailty/gait concerns. | |
clinical_flag | Reduced eGFR requires review | new | medium | structured_fact | Latest eGFR 35.0 mL/min/1.73m2 requires medication and renal-risk review. | |
clinical_flag | Repeated BP above target | completed | high | structured_fact | Two recent BP readings are above target: 142/84 and 145/83 mmHg. | |
note | SOAP note | Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | egfr | ||
note | SOAP note | BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | |
appointment | lab follow-up | completed | |
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports recent family stress. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
report | Screening | FIT negative | |
care_element | cancer_screening | FIT negative | |
report | Laboratory | Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring. | |
care_element | immunization | COVID-19 vaccine documented | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | albumin_creatinine_ratio | ||
care_element | smoking_status | not documented | |
care_element | bmi | ||
care_element | egfr | ||
care_element | immunization | Influenza vaccine documented | |
care_element | egfr | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | lab follow-up | completed | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | periodic health review | booked | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | immunization | Pneumococcal vaccine documented |
Diastolic Bp
84 mmHg
2025-08-15Systolic Bp
142 mmHg
2025-08-15Albumin Creatinine Ratio
90 mg/mmol
2025-05-22Smoking Status
not documented
2024-10-27Bmi
35 kg/m2
2024-07-28Egfr
40 mL/min/1.73m2
2024-05-16Immunization
Influenza vaccine documented
2024-04-13Egfr
40 mL/min/1.73m2
2023-12-15Diastolic Bp
72 mmHg
2023-08-06Systolic Bp
128 mmHg
2023-08-06Diastolic Bp
79 mmHg
2022-09-19Systolic Bp
141 mmHg
2022-09-19Diastolic Bp
81 mmHg
2021-11-10Systolic Bp
115 mmHg
2021-11-10Immunization
Pneumococcal vaccine documented
2021-10-24