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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: frailty_falls falls_review_due medium in_review Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_n...
membership needs review
No review task has been created from this cohort for this patient yet.
Smoking / Lung Screening review cohort
Chart evidence: Care element: smoking_status never smoker form
membership needs review
Open review tasks
3
New, in review, or accepted tasks
Last visit
2026-03-12
Appointment or derived chart contact
Latest A1c
No A1c
Missing structured value
Latest BP
119 mmHg / 78 mmHg
2024-09-27
Extracted signals
0
Optional text signals
Chart volume
29
4 notes, 2 reports
A compact view of what needs attention before opening the full imported record.
Review priority
1
active signal
3
0
0
Review these before relying on the imported record clinically.
Review needed
3 open flags
Open clinical review items need status, assignment, or closure.
Active problems
3
Frailty risk
active
Chronic knee pain
active
History of TIA/stroke
Z86.73
active
Active medications
3
Hydromorphone
1 mg q6h PRN
Rosuvastatin
20 mg daily
Atorvastatin
40 mg daily
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.
No extracted signals for this patient
Reprocess an import with text enrichment to attach suggested evidence to this patient record.
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15, 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: FALLS_REVIEW_DUE
status=in_review | imported | next review=2026-06-09 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: frailty_falls falls_review_due medium in_review Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_note | Flag: chronic_pain_opioids opioid_monitoring_due high dismissed Opioid monitoring review due Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen document... | Clinical note: SOAP note Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed. | Problem: active: Frailty risk: {"id":"PROB00029","patient_id":"PAT0015","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2022-04-02","source":"problem_list"} | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status never smoker form | probable
phm_workflow
PHM action: FALLS_REVIEW_DUE
status=in_review | imported | next review=2026-06-09 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient.
clinical_flag
Influenza immunization recall
in_review | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window.
clinical_flag
Falls risk review due
in_review | medium | clinical_note | Recent note documents 1 fall(s) in the past year with frailty/gait concerns.
clinical_flag
Opioid monitoring review due
dismissed | high | structured_fact | Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation.
clinical_flag
Vascular disease without active statin
accepted | medium | report | History of TIA/stroke documented but no active statin medication found in the synthetic medication list.
report
Consult
Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
appointment
chronic disease review
completed
note
SOAP note
Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed.
report
Screening
FIT negative
note
SOAP note
Pain follow-up for chronic knee pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 3/10.
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.
note
consult
History of TIA/stroke follow-up. Patient reports palpitations resolved. Plan: continue guideline-oriented risk management and monitor labs.
SOAP note
Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed.
SOAP note
Pain follow-up for chronic knee pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 3/10.
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.
consult
History of TIA/stroke follow-up. Patient reports palpitations resolved. Plan: continue guideline-oriented risk management and monitor labs.
Consult
Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
Screening
FIT negative
Influenza immunization recall
No recent influenza immunization evidence within the synthetic seasonal window.
Falls risk review due
Recent note documents 1 fall(s) in the past year with frailty/gait concerns.
Opioid monitoring review due
Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation.
Vascular disease without active statin
History of TIA/stroke documented but no active statin medication found in the synthetic medication list.
Cancer Screening
FIT negative
2026-02-28Bmi
18.7 kg/m2
2025-10-24Immunization
COVID-19 vaccine documented
2025-07-07Immunization
Pneumococcal vaccine documented
2024-12-02Smoking Status
never smoker
2024-10-07Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: frailty_falls falls_review_due medium in_review Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_note | Flag: chronic_pain_opioids opioid_monitoring_due high dismissed Opioid monitoring review due Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen document... | Clinical note: SOAP note Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed. | Problem: active: Frailty risk: {"id":"PROB00029","patient_id":"PAT0015","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2022-04-02","source":"problem_list"} | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status never smoker form | probable | |
phm_workflow | PHM action: FALLS_REVIEW_DUE | status=in_review | imported | next review=2026-06-09 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient. | |
clinical_flag | Influenza immunization recall | in_review | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window. | |
clinical_flag | Falls risk review due | in_review | medium | clinical_note | Recent note documents 1 fall(s) in the past year with frailty/gait concerns. | |
clinical_flag | Opioid monitoring review due | dismissed | high | structured_fact | Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation. | |
clinical_flag | Vascular disease without active statin | accepted | medium | report | History of TIA/stroke documented but no active statin medication found in the synthetic medication list. | |
report | Consult | Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed. | |
appointment | chronic disease review | completed | |
note | SOAP note | Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed. | |
report | Screening | FIT negative | |
care_element | cancer_screening | FIT negative | |
note | SOAP note | Pain follow-up for chronic knee pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 3/10. | |
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 | bmi | ||
care_element | immunization | COVID-19 vaccine documented | |
note | consult | History of TIA/stroke follow-up. Patient reports palpitations resolved. Plan: continue guideline-oriented risk management and monitor labs. | |
appointment | lab follow-up | completed | |
care_element | immunization | Pneumococcal vaccine documented | |
care_element | smoking_status | never smoker | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | medication renewal | completed | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | immunization | Influenza vaccine documented | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | lab follow-up | completed |
Diastolic Bp
78 mmHg
2024-09-27Systolic Bp
119 mmHg
2024-09-27Diastolic Bp
74 mmHg
2024-02-25Systolic Bp
117 mmHg
2024-02-25Immunization
Influenza vaccine documented
2024-02-13Diastolic Bp
80 mmHg
2023-10-23Systolic Bp
112 mmHg
2023-10-23