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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.
1, current
Smoking / Lung Screening review cohort
Chart evidence: Care element: smoking_status never smoker form
membership needs review
No review task has been created from this cohort for this patient yet.
Open review tasks
3
New, in review, or accepted tasks
Last visit
2026-05-14
Appointment or derived chart contact
Latest A1c
9.2 %
2026-05-03
Latest BP
147 mmHg / 93 mmHg
2025-11-22
Extracted signals
0
Optional text signals
Chart volume
51
6 notes, 5 reports
A compact view of what needs attention before opening the full imported record.
Review priority
3
active signal
s
3
0
0
Review these before relying on the imported record clinically.
AI-CDS actions selected from Flags & Tasks. These stay visible on the chart for follow-up.
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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37, more source rows below
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PHM saved action
PHM action: POLYPHARMACY_REVIEW
status=new | imported | outreach=sms 2026-02-23 14:00 | next review=2026-08-01 | Review evidence for Polypharmacy medication review; confirm appropriateness before contacting patient.
PHM saved action
PHM action: DIABETES_ACR_OVERDUE
status=snoozed | imported | next review=2026-06-09 | Review evidence for Urine ACR overdue; confirm appropriateness before contacting patient.
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status never smoker form | probable
phm_workflow
PHM action: POLYPHARMACY_REVIEW
status=new | imported | outreach=sms 2026-02-23 14:00 | next review=2026-08-01 | Review evidence for Polypharmacy medication review; confirm appropriateness before contacting patient.
phm_workflow
PHM action: DIABETES_ACR_OVERDUE
status=snoozed | imported | next review=2026-06-09 | Review evidence for Urine ACR overdue; confirm appropriateness before contacting patient.
clinical_flag
Polypharmacy medication review
new | medium | structured_fact | 9 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed.
clinical_flag
Sickle cell preventive care review
completed | medium | clinical_note | Sickle cell disease requires review of vaccines, fever plan, hematology follow-up, pain plan, and hydroxyurea suitability.
clinical_flag
Eye exam evidence missing or overdue
dismissed | medium | active_cohort_automation | Diabetic eye screening risk is documented but no recent eye exam report is present in the synthetic chart.
clinical_flag
Urine ACR overdue
in_review | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
clinical_flag
HbA1c above target
dismissed | high | structured_fact | Latest HbA1c 9.2% suggests above-target glycemic control and needs clinician review.
alert
Diabetes control flag: HbA1c above target
Generated from longitudinal lab trend.
clinical_flag
Possible diabetes monitoring care gap
new | medium | structured | Confirmed diabetes evidence found, but no recent A1c/HbA1c care element was imported.
appointment
medication renewal
completed
note
SOAP note
BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance.
report
Consult
Oncology follow-up for breast cancer survivor. No active recurrence noted in this synthetic report. Ongoing surveillance, late effects, and primary care coordination discussed.
note
SOAP note
Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports no acute concern. Plan: update labs/vitals and arrange follow-up as clinically indicated.
SOAP note
BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance.
SOAP note
Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports no acute concern. Plan: update labs/vitals and arrange follow-up as clinically indicated.
SOAP note
Sickle cell follow-up. Vaso-occlusive pain episodes in past year: 0. Reviewed hydration, fever precautions, vaccination status, and hematology follow-up.
SOAP note
T2DM review. Home glucose pattern often elevated fasting. Discussed nutrition, exercise, foot care, and medication adherence. Plan: repeat HbA1c and review cardiovascular/renal risk.
Possible diabetes monitoring care gap
Confirmed diabetes evidence found, but no recent A1c/HbA1c care element was imported.
Polypharmacy medication review
9 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed.
Sickle cell preventive care review
Sickle cell disease requires review of vaccines, fever plan, hematology follow-up, pain plan, and hydroxyurea suitability.
Eye exam evidence missing or overdue
Diabetic eye screening risk is documented but no recent eye exam report is present in the synthetic chart.
Urine ACR overdue
Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
HbA1c above target
Latest HbA1c 9.2% suggests above-target glycemic control and needs clinician review.
Review needed
3 open flags
Open clinical review items need status, assignment, or closure.
A1c above review threshold
Latest HbA1c is 9.2 % on 2026-05-03.
BP above target
Latest BP is 147 mmHg / 93 mmHg on 2025-11-22.
Active problems
6
Sickle cell disease
D57.1
active
Diabetic eye screening risk
active
Breast cancer survivor
active
Coronary artery disease
I25.10
active
Essential hypertension
I10
active
Active medications
9
Hydroxyurea
500 mg daily
Folic acid
1 mg daily
Rosuvastatin
20 mg daily
Metoprolol
25 mg BID
Apixaban
Consult
Oncology follow-up for breast cancer survivor. No active recurrence noted in this synthetic report. Ongoing surveillance, late effects, and primary care coordination discussed.
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
Consult
Consult follow-up for Coronary artery disease. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
Laboratory
CBC and hemolysis markers reviewed for sickle cell disease monitoring.
Ldl Cholesterol
2.2 mmol/L
2026-05-07Hba1c
9.2 %
2026-05-03Egfr
65 mL/min/1.73m2
2025-12-10Diastolic Bp
93 mmHg
2025-11-22Systolic Bp
147 mmHg
2025-11-22Hba1c
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status never smoker form | probable | |
phm_workflow | PHM action: POLYPHARMACY_REVIEW | status=new | imported | outreach=sms 2026-02-23 14:00 | next review=2026-08-01 | Review evidence for Polypharmacy medication review; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: DIABETES_ACR_OVERDUE | status=snoozed | imported | next review=2026-06-09 | Review evidence for Urine ACR overdue; confirm appropriateness before contacting patient. | |
clinical_flag | Polypharmacy medication review | new | medium | structured_fact | 9 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed. | |
clinical_flag | Sickle cell preventive care review | completed | medium | clinical_note | Sickle cell disease requires review of vaccines, fever plan, hematology follow-up, pain plan, and hydroxyurea suitability. | |
clinical_flag | Eye exam evidence missing or overdue | dismissed | medium | active_cohort_automation | Diabetic eye screening risk is documented but no recent eye exam report is present in the synthetic chart. | |
clinical_flag | Urine ACR overdue | in_review | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window. | |
clinical_flag | HbA1c above target | dismissed | high | structured_fact | Latest HbA1c 9.2% suggests above-target glycemic control and needs clinician review. | |
alert | Diabetes control flag: HbA1c above target | Generated from longitudinal lab trend. | |
clinical_flag | Possible diabetes monitoring care gap | new | medium | structured | Confirmed diabetes evidence found, but no recent A1c/HbA1c care element was imported. | |
appointment | medication renewal | completed | |
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
note | SOAP note | BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | |
report | Consult | Oncology follow-up for breast cancer survivor. No active recurrence noted in this synthetic report. Ongoing surveillance, late effects, and primary care coordination discussed. | |
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports no acute concern. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
care_element | egfr | ||
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. | |
note | SOAP note | Sickle cell follow-up. Vaso-occlusive pain episodes in past year: 0. Reviewed hydration, fever precautions, vaccination status, and hematology follow-up. | |
report | Consult | Consult follow-up for Coronary artery disease. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed. | |
note | SOAP note | T2DM review. Home glucose pattern often elevated fasting. Discussed nutrition, exercise, foot care, and medication adherence. Plan: repeat HbA1c and review cardiovascular/renal risk. | |
care_element | hba1c | ||
note | consult | Survivorship care reviewed for history of breast cancer survivor. Patient asks about surveillance schedule and late effects. | |
note | consult | Coronary artery disease follow-up. Patient reports leg discomfort with walking. Plan: continue guideline-oriented risk management and monitor labs. | |
care_element | ldl_cholesterol | ||
care_element | bmi | ||
appointment | same-day concern | completed | |
report | Laboratory | CBC and hemolysis markers reviewed for sickle cell disease monitoring. | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | hba1c | ||
care_element | smoking_status | never smoker | |
appointment | periodic health review | completed | |
care_element | ldl_cholesterol | ||
report | Screening | FIT negative | |
care_element | cancer_screening | FIT negative | |
care_element | fasting_glucose | ||
appointment | same-day concern | completed | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
care_element | hba1c | ||
care_element | ldl_cholesterol | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | same-day concern | completed | |
care_element | hba1c | ||
appointment | periodic health review | completed |
5 mg BID
Screening
FIT negative
10 %
2025-06-19Ldl Cholesterol
1.8 mmol/L
2025-06-05Bmi
21.5 kg/m2
2025-02-28Diastolic Bp
76 mmHg
2024-12-03Systolic Bp
135 mmHg
2024-12-03Hba1c
9.3 %
2024-10-28Smoking Status
never smoker
2024-07-24Ldl Cholesterol
1.8 mmol/L
2024-06-16Cancer Screening
FIT negative
2024-02-18Fasting Glucose
9.8 mmol/L
2023-12-06Diastolic Bp
80 mmHg
2023-04-22Systolic Bp
143 mmHg
2023-04-22Ldl Cholesterol
1.3 mmol/L
2023-03-21Hba1c
9.3 %
2023-01-25Hba1c
8.7 %
2022-08-06Ldl Cholesterol
1.9 mmol/L
2022-04-05Diastolic Bp
79 mmHg
2022-03-20Systolic Bp
127 mmHg
2022-03-20Hba1c
8.8 %
2021-11-25