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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
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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 in_review Recurrent falls risk Recent note documents 2 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 in_review Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note...
Open review tasks
2
New, in review, or accepted tasks
Last visit
2026-03-07
Appointment or derived chart contact
Latest A1c
8.7 %
2026-03-13
Latest BP
123 mmHg / 80 mmHg
2025-04-28
Extracted signals
0
Optional text signals
Chart volume
44
4 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 8.7 % on 2026-03-13.
Active problems
4
Diabetic eye screening risk
active
Frailty risk
active
Essential hypertension
I10
active
Type 2 diabetes mellitus
E11
active
Active medications
2
Candesartan
8 mg daily
Empagliflozin
10 mg daily
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
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Saved population-health queue work for this patient: calls, recalls, flags, snoozes, exclusions, and completions.
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30, 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: RECURRENT_FALLS
status=new | imported | outreach=portal 2026-03-28 15:30 | next review=2026-06-23 | 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 in_review Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | Clinical note: SOAP note BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | 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. | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Flag: frailty_falls recurrent_falls high in_review 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: RECURRENT_FALLS
status=new | imported | outreach=portal 2026-03-28 15:30 | next review=2026-06-23 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
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
Recurrent falls risk
in_review | high | clinical_note | Recent note documents 2 fall(s) in the past year with frailty/gait concerns.
clinical_flag
HbA1c above target
completed | high | structured_fact | Latest HbA1c 8.7% suggests above-target glycemic control and needs clinician review.
alert
Diabetes control flag: HbA1c above target
Generated from longitudinal lab trend.
note
SOAP note
Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed.
note
SOAP note
BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance.
appointment
periodic health review
completed
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.
appointment
chronic disease review
completed
report
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
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.
SOAP note
Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed.
SOAP note
BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance.
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.
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.
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
Eye exam evidence missing or overdue
Diabetic eye screening risk is documented but no recent eye exam report is present in the synthetic chart.
Recurrent falls risk
Recent note documents 2 fall(s) in the past year with frailty/gait concerns.
HbA1c above target
Latest HbA1c 8.7% suggests above-target glycemic control and needs clinician review.
Ldl Cholesterol
2.8 mmol/L
2026-05-15Albumin Creatinine Ratio
21.8 mg/mmol
2026-05-04Hba1c
8.7 %
2026-03-13Fasting Glucose
7.1 mmol/L
2026-02-21Diastolic Bp
80 mmHg
2025-04-28Systolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: frailty_falls recurrent_falls high in_review Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | Clinical note: SOAP note BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | 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. | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Flag: frailty_falls recurrent_falls high in_review 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: RECURRENT_FALLS | status=new | imported | outreach=portal 2026-03-28 15:30 | next review=2026-06-23 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient. | |
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 | Recurrent falls risk | in_review | high | clinical_note | Recent note documents 2 fall(s) in the past year with frailty/gait concerns. | |
clinical_flag | HbA1c above target | completed | high | structured_fact | Latest HbA1c 8.7% suggests above-target glycemic control and needs clinician review. | |
alert | Diabetes control flag: HbA1c above target | Generated from longitudinal lab trend. | |
note | SOAP note | Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | |
care_element | ldl_cholesterol | ||
care_element | albumin_creatinine_ratio | ||
care_element | hba1c | ||
note | SOAP note | BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | |
appointment | periodic health review | completed | |
care_element | fasting_glucose | ||
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. | |
appointment | chronic disease review | completed | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
care_element | fasting_glucose | ||
care_element | hba1c | ||
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 | bmi | ||
care_element | smoking_status | never smoker | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | fasting_glucose | ||
appointment | medication renewal | completed | |
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | egfr | ||
care_element | fasting_glucose | ||
care_element | hba1c | ||
care_element | ldl_cholesterol | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
appointment | periodic health review | cancelled | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | chronic disease review | no_show |
123 mmHg
2025-04-28Fasting Glucose
9.9 mmol/L
2025-04-06Hba1c
7.6 %
2025-02-07Bmi
26.1 kg/m2
2024-08-29Smoking Status
never smoker
2024-07-29Diastolic Bp
69 mmHg
2024-07-07Systolic Bp
124 mmHg
2024-07-07Fasting Glucose
9.1 mmol/L
2024-06-07Ldl Cholesterol
3.9 mmol/L
2024-02-17Hba1c
7.6 %
2024-01-21Diastolic Bp
79 mmHg
2023-12-08Systolic Bp
131 mmHg
2023-12-08Egfr
93 mL/min/1.73m2
2023-08-18Fasting Glucose
9.1 mmol/L
2023-06-25Hba1c
7.1 %
2023-04-23Ldl Cholesterol
1.3 mmol/L
2023-03-22Diastolic Bp
89 mmHg
2022-04-21Systolic Bp
139 mmHg
2022-04-21Ldl Cholesterol
3.2 mmol/L
2022-01-06Hba1c
7.5 %
2021-08-12Diastolic Bp
87 mmHg
2021-02-12Systolic Bp
137 mmHg
2021-02-12