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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: diabetes_prediabetes prediabetes_risk medium new Prediabetes range HbA1c Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list dia...
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 accepted Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note |...
Open review tasks
4
New, in review, or accepted tasks
Last visit
2026-03-20
Appointment or derived chart contact
Latest A1c
5.8 %
2026-02-14
Latest BP
111 mmHg / 75 mmHg
2025-10-02
Extracted signals
0
Optional text signals
Chart volume
37
6 notes, 0 reports
A compact view of what needs attention before opening the full imported record.
Review priority
1
active signal
4
0
0
Review these before relying on the imported record clinically.
Review needed
4 open flags
Open clinical review items need status, assignment, or closure.
Active problems
5
Frailty risk
active
Osteoarthritis of hip
M19.90
active
Chronic neck pain
active
Vascular dementia
F03
active
Prediabetes
R73.03
active
Active medications
1
Acetaminophen
1000 mg TID PRN
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.
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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.
23, more source rows below
Latest narrative evidence, clipped for scanning.
Recent report headers and excerpts.
No reports imported
Audit view for imported records. Kept collapsed so the working chart remains usable.
PHM saved action
PHM action: PNEUMOCOCCAL_REVIEW_DUE
status=booked | imported | next review=2026-06-23 | Review evidence for Pneumococcal immunization review; confirm appropriateness before contacting patient.
PHM saved action
PHM action: RECURRENT_FALLS
status=new | imported | outreach=phone 2026-03-21 12:15 | next review=2026-06-23 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
PHM saved action
PHM action: DEMENTIA_CARE_PLAN_DUE
status=new | imported | next review=2026-06-09 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: diabetes_prediabetes prediabetes_risk medium new Prediabetes range HbA1c Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Flag: dementia dementia_care_plan_due medium in_review 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 accepted Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Cognitive follow-up. Family reports missed bills. 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 accepted Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Care element: smoking_status current smoker form | probable
phm_workflow
PHM action: PNEUMOCOCCAL_REVIEW_DUE
status=booked | imported | next review=2026-06-23 | Review evidence for Pneumococcal immunization review; confirm appropriateness before contacting patient.
phm_workflow
PHM action: RECURRENT_FALLS
status=new | imported | outreach=phone 2026-03-21 12:15 | next review=2026-06-23 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
phm_workflow
PHM action: DEMENTIA_CARE_PLAN_DUE
status=new | imported | next review=2026-06-09 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient.
clinical_flag
Pneumococcal immunization review
accepted | medium | active_cohort_automation | Older adult with no pneumococcal immunization evidence in the synthetic chart.
clinical_flag
Influenza immunization recall
dismissed | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window.
clinical_flag
Recurrent falls risk
accepted | high | clinical_note | Recent note documents 2 fall(s) in the past year with frailty/gait concerns.
clinical_flag
Dementia care plan review
in_review | medium | clinical_note | Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed.
clinical_flag
Prediabetes range HbA1c
new | medium | structured_fact | Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis.
note
SOAP note
Pain follow-up for chronic neck pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 9/10.
note
preventive care
HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented.
appointment
same-day concern
completed
note
SOAP note
Cognitive follow-up. Family reports missed bills. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
SOAP note
Pain follow-up for chronic neck pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 9/10.
preventive care
HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented.
SOAP note
Cognitive follow-up. Family reports missed bills. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
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.
Pneumococcal immunization review
Older adult with no pneumococcal immunization evidence in the synthetic chart.
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.
Prediabetes range HbA1c
Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis.
Hba1c
5.8 %
2026-02-14Bmi
20.8 kg/m2
2026-01-08Smoking Status
current smoker
2026-01-06Diastolic Bp
75 mmHg
2025-10-02Systolic Bp
111 mmHg
2025-10-02Immunization
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: diabetes_prediabetes prediabetes_risk medium new Prediabetes range HbA1c Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Flag: dementia dementia_care_plan_due medium in_review 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 accepted Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Cognitive follow-up. Family reports missed bills. 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 accepted Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Care element: smoking_status current smoker form | probable | |
phm_workflow | PHM action: PNEUMOCOCCAL_REVIEW_DUE | status=booked | imported | next review=2026-06-23 | Review evidence for Pneumococcal immunization review; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: RECURRENT_FALLS | status=new | imported | outreach=phone 2026-03-21 12:15 | next review=2026-06-23 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: DEMENTIA_CARE_PLAN_DUE | status=new | imported | next review=2026-06-09 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient. | |
clinical_flag | Pneumococcal immunization review | accepted | medium | active_cohort_automation | Older adult with no pneumococcal immunization evidence in the synthetic chart. | |
clinical_flag | Influenza immunization recall | dismissed | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window. | |
clinical_flag | Recurrent falls risk | accepted | high | clinical_note | Recent note documents 2 fall(s) in the past year with frailty/gait concerns. | |
clinical_flag | Dementia care plan review | in_review | medium | clinical_note | Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. | |
clinical_flag | Prediabetes range HbA1c | new | medium | structured_fact | Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis. | |
note | SOAP note | Pain follow-up for chronic neck pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 9/10. | |
note | preventive care | HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented. | |
appointment | same-day concern | completed | |
care_element | hba1c | ||
note | SOAP note | Cognitive follow-up. Family reports missed bills. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | |
care_element | bmi | ||
care_element | smoking_status | current smoker | |
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. | |
appointment | chronic disease review | completed | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | immunization | COVID-19 vaccine documented | |
note | SOAP note | MSK review: chronic hip pain with morning stiffness and crepitus, consistent with osteoarthritis pattern. Discussed activity modification, strengthening, topical/oral analgesia risks, imaging only if red flags or surgical planning. | |
care_element | immunization | Influenza vaccine documented | |
care_element | hba1c | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | lab follow-up | completed | |
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 | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | hba1c | ||
care_element | egfr | ||
appointment | periodic health review | completed | |
appointment | chronic disease review | completed | |
care_element | hba1c | ||
appointment | chronic disease review | completed |
COVID-19 vaccine documented
2025-05-08Immunization
Influenza vaccine documented
2025-02-07Hba1c
5.8 %
2025-01-18Diastolic Bp
69 mmHg
2024-12-04Systolic Bp
116 mmHg
2024-12-04Diastolic Bp
63 mmHg
2024-05-05Systolic Bp
118 mmHg
2024-05-05Hba1c
6.1 %
2023-10-26Egfr
97 mL/min/1.73m2
2023-10-23Hba1c
5.7 %
2021-11-16