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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 dismissed Recurrent falls risk Recent note documents 3 fall(s) in the past year with frailty/gait concerns. clinical_note...
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 dismissed Recurrent falls risk Recent note documents 3 fall(s) in the past year with frailty/gait concerns. clinical_note...
Open review tasks
0
New, in review, or accepted tasks
Last visit
2024-01-16
Appointment or derived chart contact
Latest A1c
5.3 %
2025-11-22
Latest BP
127 mmHg / 82 mmHg
2026-03-27
Extracted signals
0
Optional text signals
Chart volume
23
3 notes, 1 reports
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Review priority
0
active signal
s
0
0
0
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No signals
No immediate review signals
No open flags or obvious structured high-risk values are attached to this imported chart.
Active problems
2
Frailty risk
active
Essential hypertension
I10
active
Active medications
2
Candesartan
8 mg daily
Amlodipine
5 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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13, more source rows below
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Audit view for imported records. Kept collapsed so the working chart remains usable.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: frailty_falls recurrent_falls high dismissed Recurrent falls risk Recent note documents 3 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | Clinical note: SOAP note Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed. | Problem: active: Frailty risk: {"id":"PROB00261","patient_id":"PAT0125","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2023-05-14","source":"problem_list"} | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Flag: frailty_falls recurrent_falls high dismissed Recurrent falls risk Recent note documents 3 fall(s) in the past year with frailty/gait concerns. clinical_note | Care element: smoking_status former smoker form | probable
clinical_flag
Recurrent falls risk
dismissed | high | clinical_note | Recent note documents 3 fall(s) in the past year with frailty/gait concerns.
note
SOAP note
BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance.
report
Screening
FIT negative
note
SOAP note
Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed.
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
medication renewal
completed
appointment
lab follow-up
completed
appointment
chronic disease review
completed
SOAP note
BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance.
SOAP note
Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed.
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.
Screening
FIT negative
Recurrent falls risk
Recent note documents 3 fall(s) in the past year with frailty/gait concerns.
Diastolic Bp
82 mmHg
2026-03-27Systolic Bp
127 mmHg
2026-03-27Cancer Screening
FIT negative
2026-02-17Hba1c
5.3 %
2025-11-22Bmi
20.1 kg/m2
2025-10-19Egfr
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: frailty_falls recurrent_falls high dismissed Recurrent falls risk Recent note documents 3 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | Clinical note: SOAP note Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed. | Problem: active: Frailty risk: {"id":"PROB00261","patient_id":"PAT0125","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2023-05-14","source":"problem_list"} | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Flag: frailty_falls recurrent_falls high dismissed Recurrent falls risk Recent note documents 3 fall(s) in the past year with frailty/gait concerns. clinical_note | Care element: smoking_status former smoker form | probable | |
clinical_flag | Recurrent falls risk | dismissed | high | clinical_note | Recent note documents 3 fall(s) in the past year with frailty/gait concerns. | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
note | SOAP note | BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | |
report | Screening | FIT negative | |
care_element | cancer_screening | FIT negative | |
care_element | hba1c | ||
note | SOAP note | Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed. | |
care_element | bmi | ||
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. | |
care_element | egfr | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | smoking_status | former smoker | |
appointment | medication renewal | completed | |
appointment | lab follow-up | completed | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | chronic disease review | completed |
81 mL/min/1.73m2
2025-09-01Diastolic Bp
81 mmHg
2025-04-25Systolic Bp
113 mmHg
2025-04-25Smoking Status
former smoker
2024-09-25Diastolic Bp
75 mmHg
2022-08-12Systolic Bp
124 mmHg
2022-08-12Diastolic Bp
75 mmHg
2021-09-10Systolic Bp
134 mmHg
2021-09-10