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Accepted chart labels
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Cohort memberships
Patient-list membership from saved cohort runs. These are source lists, not task status or accepted chart labels.
1, current
Smoking / Lung Screening review cohort
Chart evidence: Flag: copd copd_recurrent_exacerbation high accepted Recurrent COPD exacerbation pattern Multiple COPD-related visits/exacerbation language identified within the r...
membership needs review
No review task has been created from this cohort for this patient yet.
Open review tasks
6
New, in review, or accepted tasks
Last visit
2026-03-16
Appointment or derived chart contact
Latest A1c
8.2 %
2026-05-08
Latest BP
138 mmHg / 72 mmHg
2026-02-23
Extracted signals
0
Optional text signals
Chart volume
54
7 notes, 3 reports
A compact view of what needs attention before opening the full imported record.
Review priority
2
active signal
s
6
0
0
Review these before relying on the imported record clinically.
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0, selected
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Saved population-health queue work for this patient: calls, recalls, flags, snoozes, exclusions, and completions.
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Reprocess an import with text enrichment to attach suggested evidence to this patient record.
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40, more source rows below
Latest narrative evidence, clipped for scanning.
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Audit view for imported records. Kept collapsed so the working chart remains usable.
PHM saved action
PHM action: OPIOID_MONITORING_DUE
status=outreach_planned | imported | outreach=phone 2026-05-02 08:50 | next review=2026-07-17 | Review evidence for Opioid monitoring review due; confirm appropriateness before contacting patient.
PHM saved action
PHM action: MODERATE_SEVERE_SYMPTOM_SCORE
status=outreach_planned | imported | next review=2026-06-23 | Review evidence for Elevated mental health symptom score; confirm appropriateness before contacting patient.
PHM saved action
PHM action: COPD_RECURRENT_EXACERBATION
status=snoozed | imported | next review=2026-06-09 | Review evidence for Recurrent COPD exacerbation pattern; confirm appropriateness before contacting patient.
PHM saved action
PHM action: UNCONTROLLED_HBA1C
status=in_review | imported | outreach=sms 2026-03-22 16:50 | next review=2026-07-17 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient.
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Flag: copd copd_recurrent_exacerbation high accepted Recurrent COPD exacerbation pattern Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period. clinical_note | Care element: smoking_status current smoker form | probable
phm_workflow
PHM action: OPIOID_MONITORING_DUE
status=outreach_planned | imported | outreach=phone 2026-05-02 08:50 | next review=2026-07-17 | Review evidence for Opioid monitoring review due; confirm appropriateness before contacting patient.
phm_workflow
PHM action: MODERATE_SEVERE_SYMPTOM_SCORE
status=outreach_planned | imported | next review=2026-06-23 | Review evidence for Elevated mental health symptom score; confirm appropriateness before contacting patient.
phm_workflow
PHM action: COPD_RECURRENT_EXACERBATION
status=snoozed | imported | next review=2026-06-09 | Review evidence for Recurrent COPD exacerbation pattern; confirm appropriateness before contacting patient.
phm_workflow
PHM action: UNCONTROLLED_HBA1C
status=in_review | imported | outreach=sms 2026-03-22 16:50 | next review=2026-07-17 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient.
clinical_flag
Polypharmacy medication review
new | medium | structured_fact | 11 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed.
clinical_flag
Opioid monitoring review due
in_review | high | structured_fact | Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation.
clinical_flag
Elevated mental health symptom score
in_review | high | clinical_note | Recent note documents PHQ-9 14 and GAD-7 19; follow-up priority should be reviewed.
clinical_flag
Recurrent COPD exacerbation pattern
accepted | high | clinical_note | Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period.
clinical_flag
Urine ACR overdue
accepted | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
clinical_flag
HbA1c above target
new | high | structured_fact | Latest HbA1c 8.2% suggests above-target glycemic control and needs clinician review.
alert
Diabetes control flag: HbA1c above target
Generated from longitudinal lab trend.
note
SOAP note
BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance.
note
SOAP note
COPD review. Symptoms include shortness of breath on stairs. Inhaler technique reviewed. Exacerbation risk discussed.
SOAP note
BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance.
SOAP note
COPD review. Symptoms include shortness of breath on stairs. Inhaler technique reviewed. Exacerbation risk discussed.
SOAP note
Pain follow-up for chronic low back pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 6/10.
SOAP note
Mental health review. PHQ-9 14, GAD-7 19. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
Laboratory
Spirometry: obstructive pattern compatible with COPD; post-bronchodilator values documented in scanned pulmonary function report.
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
Screening
colonoscopy complete
Polypharmacy medication review
11 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed.
Opioid monitoring review due
Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation.
Elevated mental health symptom score
Recent note documents PHQ-9 14 and GAD-7 19; follow-up priority should be reviewed.
Recurrent COPD exacerbation pattern
Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period.
Urine ACR overdue
Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
HbA1c above target
Latest HbA1c 8.2% suggests above-target glycemic control and needs clinician review.
Review needed
6 open flags
Open clinical review items need status, assignment, or closure.
A1c above review threshold
Latest HbA1c is 8.2 % on 2026-05-08.
Active problems
5
Chronic low back pain
active
Generalized anxiety disorder
active
Chronic obstructive pulmonary disease
J44.9
active
Essential hypertension
I10
active
Type 2 diabetes mellitus
E11
active
Active medications
11
Hydromorphone
1 mg q6h PRN
Duloxetine
30 mg daily
Celecoxib
100 mg BID PRN
Tiotropium inhaler
18 mcg daily
Salbutamol inhaler
Ldl Cholesterol
2.8 mmol/L
2026-05-08Hba1c
8.2 %
2026-05-08Egfr
56 mL/min/1.73m2
2026-04-21Diastolic Bp
72 mmHg
2026-02-23Systolic Bp
138 mmHg
2026-02-23Diastolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Flag: copd copd_recurrent_exacerbation high accepted Recurrent COPD exacerbation pattern Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period. clinical_note | Care element: smoking_status current smoker form | probable | |
phm_workflow | PHM action: OPIOID_MONITORING_DUE | status=outreach_planned | imported | outreach=phone 2026-05-02 08:50 | next review=2026-07-17 | Review evidence for Opioid monitoring review due; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: MODERATE_SEVERE_SYMPTOM_SCORE | status=outreach_planned | imported | next review=2026-06-23 | Review evidence for Elevated mental health symptom score; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: COPD_RECURRENT_EXACERBATION | status=snoozed | imported | next review=2026-06-09 | Review evidence for Recurrent COPD exacerbation pattern; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: UNCONTROLLED_HBA1C | status=in_review | imported | outreach=sms 2026-03-22 16:50 | next review=2026-07-17 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient. | |
clinical_flag | Polypharmacy medication review | new | medium | structured_fact | 11 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed. | |
clinical_flag | Opioid monitoring review due | in_review | high | structured_fact | Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation. | |
clinical_flag | Elevated mental health symptom score | in_review | high | clinical_note | Recent note documents PHQ-9 14 and GAD-7 19; follow-up priority should be reviewed. | |
clinical_flag | Recurrent COPD exacerbation pattern | accepted | high | clinical_note | Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period. | |
clinical_flag | Urine ACR overdue | accepted | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window. | |
clinical_flag | HbA1c above target | new | high | structured_fact | Latest HbA1c 8.2% suggests above-target glycemic control and needs clinician review. | |
alert | Diabetes control flag: HbA1c above target | Generated from longitudinal lab trend. | |
note | SOAP note | BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | |
care_element | hba1c | ||
care_element | ldl_cholesterol | ||
care_element | egfr | ||
note | SOAP note | COPD review. Symptoms include shortness of breath on stairs. Inhaler technique reviewed. Exacerbation risk discussed. | |
appointment | same-day concern | booked | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
report | Laboratory | Spirometry: obstructive pattern compatible with COPD; post-bronchodilator values documented in scanned pulmonary function report. | |
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
note | SOAP note | Pain follow-up for chronic low back pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 6/10. | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
note | SOAP note | Mental health review. PHQ-9 14, GAD-7 19. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | |
note | SOAP note | COPD review. Symptoms include wheeze during viral illness. Inhaler technique reviewed. Exacerbation risk discussed. | |
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. | |
care_element | fasting_glucose | ||
appointment | chronic disease review | completed | |
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports variable energy. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
care_element | smoking_status | current smoker | |
care_element | bmi | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
report | Screening | colonoscopy complete | |
care_element | cancer_screening | colonoscopy complete | |
care_element | fasting_glucose | ||
care_element | ldl_cholesterol | ||
appointment | chronic disease review | completed | |
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | ldl_cholesterol | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | same-day concern | completed | |
care_element | hba1c | ||
appointment | periodic health review | completed |
100 mcg 1-2 puffs q4h PRN
83 mmHg
2025-11-02Systolic Bp
136 mmHg
2025-11-02Fasting Glucose
7.8 mmol/L
2025-05-26Ldl Cholesterol
2.9 mmol/L
2025-02-06Hba1c
8.4 %
2025-02-03Smoking Status
current smoker
2024-10-30Bmi
23.5 kg/m2
2024-10-10Diastolic Bp
85 mmHg
2024-04-10Systolic Bp
129 mmHg
2024-04-10Cancer Screening
colonoscopy complete
2024-03-03Fasting Glucose
11.4 mmol/L
2024-01-21Ldl Cholesterol
1.9 mmol/L
2023-11-18Hba1c
8 %
2023-09-12Diastolic Bp
81 mmHg
2023-02-14Systolic Bp
125 mmHg
2023-02-14Ldl Cholesterol
3.9 mmol/L
2022-09-28Diastolic Bp
73 mmHg
2022-09-22Systolic Bp
127 mmHg
2022-09-22Hba1c
7.8 %
2022-03-08Diastolic Bp
80 mmHg
2021-11-12Systolic Bp
129 mmHg
2021-11-12Hba1c
8.5 %
2021-01-15