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Population Health
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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.
2, current
Frailty / Falls 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 | Clin...
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
2
New, in review, or accepted tasks
Last visit
2026-04-01
Appointment or derived chart contact
Latest A1c
8.3 %
2026-05-22
Latest BP
136 mmHg / 78 mmHg
2026-04-02
Extracted signals
0
Optional text signals
Chart volume
44
5 notes, 1 reports
A compact view of what needs attention before opening the full imported record.
Review priority
2
active signal
s
2
0
0
Review these before relying on the imported record clinically.
Review needed
2 open flags
Open clinical review items need status, assignment, or closure.
A1c above review threshold
Latest HbA1c is 8.3 % on 2026-05-22.
Active problems
4
Frailty risk
active
Major depressive disorder
active
Essential hypertension
I10
active
Type 2 diabetes mellitus
E11
active
Active medications
5
Ramipril
5 mg daily
Candesartan
8 mg daily
Hydrochlorothiazide
12.5 mg daily
Metformin
500 mg BID
Empagliflozin
10 mg daily
membership needs review
No review task has been created from this cohort for this patient yet.
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0, selected
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30, more source rows below
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PHM saved action
PHM action: RECURRENT_FALLS
status=snoozed | imported | next review=2026-07-17 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls 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 | Clinical 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. | Clinical 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. | Clinical note: SOAP note Mental health review. PHQ-9 17, GAD-7 12. Sleep fragmented. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | 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 former smoker form | probable
phm_workflow
PHM action: RECURRENT_FALLS
status=snoozed | imported | next review=2026-07-17 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
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
Elevated mental health symptom score
in_review | high | clinical_note | Recent note documents PHQ-9 17 and GAD-7 12; follow-up priority should be reviewed.
clinical_flag
HbA1c above target
completed | high | structured_fact | Latest HbA1c 8.3% 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 often elevated fasting. Discussed nutrition, exercise, foot care, and medication adherence. Plan: repeat HbA1c and review cardiovascular/renal risk.
appointment
chronic disease review
completed
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.
note
SOAP note
Mental health review. PHQ-9 17, GAD-7 12. Sleep fragmented. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
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.
note
SOAP note
BP reviewed. Home readings mostly controlled. Reviewed sodium, adherence, and medication tolerance.
report
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
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.
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.
SOAP note
Mental health review. PHQ-9 17, GAD-7 12. Sleep fragmented. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
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.
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
Recurrent falls risk
Recent note documents 2 fall(s) in the past year with frailty/gait concerns.
Elevated mental health symptom score
Recent note documents PHQ-9 17 and GAD-7 12; follow-up priority should be reviewed.
HbA1c above target
Latest HbA1c 8.3% suggests above-target glycemic control and needs clinician review.
Hba1c
8.3 %
2026-05-22Fasting Glucose
8.7 mmol/L
2026-05-04Diastolic Bp
78 mmHg
2026-04-02Systolic Bp
136 mmHg
2026-04-02Albumin Creatinine Ratio
22.7 mg/mmol
2026-02-13Ldl Cholesterol
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls 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 | Clinical 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. | Clinical 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. | Clinical note: SOAP note Mental health review. PHQ-9 17, GAD-7 12. Sleep fragmented. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | 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 former smoker form | probable | |
phm_workflow | PHM action: RECURRENT_FALLS | status=snoozed | imported | next review=2026-07-17 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient. | |
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 | Elevated mental health symptom score | in_review | high | clinical_note | Recent note documents PHQ-9 17 and GAD-7 12; follow-up priority should be reviewed. | |
clinical_flag | HbA1c above target | completed | high | structured_fact | Latest HbA1c 8.3% suggests above-target glycemic control and needs clinician review. | |
alert | Diabetes control flag: HbA1c above target | Generated from longitudinal lab trend. | |
care_element | hba1c | ||
care_element | fasting_glucose | ||
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. | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | chronic disease review | completed | |
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 | albumin_creatinine_ratio | ||
care_element | ldl_cholesterol | ||
note | SOAP note | Mental health review. PHQ-9 17, GAD-7 12. Sleep fragmented. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | |
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. | |
note | SOAP note | BP reviewed. Home readings mostly controlled. Reviewed sodium, adherence, and medication tolerance. | |
care_element | hba1c | ||
care_element | egfr | ||
care_element | ldl_cholesterol | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | smoking_status | former smoker | |
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
appointment | lab follow-up | completed | |
care_element | fasting_glucose | ||
care_element | bmi | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | ldl_cholesterol | ||
appointment | same-day concern | cancelled | |
appointment | medication renewal | completed | |
care_element | ldl_cholesterol | ||
care_element | fasting_glucose | ||
care_element | hba1c | ||
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | medication renewal | completed |
1.8 mmol/L
2026-01-20Hba1c
9.7 %
2025-10-11Egfr
49 mL/min/1.73m2
2025-09-02Ldl Cholesterol
1.8 mmol/L
2025-08-18Diastolic Bp
77 mmHg
2025-06-24Systolic Bp
122 mmHg
2025-06-24Smoking Status
former smoker
2025-02-22Fasting Glucose
11.4 mmol/L
2024-12-01Bmi
31.3 kg/m2
2024-10-31Diastolic Bp
74 mmHg
2024-07-16Systolic Bp
141 mmHg
2024-07-16Ldl Cholesterol
1.3 mmol/L
2024-04-22Ldl Cholesterol
3.4 mmol/L
2023-10-25Fasting Glucose
8.2 mmol/L
2023-01-28Hba1c
8.5 %
2023-01-20Hba1c
8.7 %
2022-07-04Diastolic Bp
66 mmHg
2022-03-08Systolic Bp
128 mmHg
2022-03-08Hba1c
8.8 %
2021-07-23Diastolic Bp
79 mmHg
2021-06-20Systolic Bp
134 mmHg
2021-06-20