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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 new Falls risk review due Recent note documents 1 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: Care element: smoking_status never smoker form
membership needs review
Open review tasks
1
New, in review, or accepted tasks
Last visit
2026-02-28
Appointment or derived chart contact
Latest A1c
7.4 %
2026-05-12
Latest BP
155 mmHg / 91 mmHg
2026-03-17
Extracted signals
0
Optional text signals
Chart volume
37
4 notes, 2 reports
A compact view of what needs attention before opening the full imported record.
Review priority
2
active signal
s
1
0
0
Review these before relying on the imported record clinically.
Review needed
1 open flag
Open clinical review items need status, assignment, or closure.
BP above target
Latest BP is 155 mmHg / 91 mmHg on 2026-03-17.
Active problems
3
Frailty risk
active
Essential hypertension
I10
active
Type 2 diabetes mellitus
E11
active
Active medications
4
Hydrochlorothiazide
12.5 mg daily
Amlodipine
5 mg daily
Gliclazide MR
30 mg daily
Metformin
500 mg BID
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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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.
Audit view for imported records. Kept collapsed so the working chart remains usable.
PHM saved action
PHM action: FALLS_REVIEW_DUE
status=outreach_planned | imported | next review=2026-06-23 | 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 new Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | Clinical note: SOAP note Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | Clinical 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. | 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=outreach_planned | imported | next review=2026-06-23 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient.
clinical_flag
Falls risk review due
new | medium | clinical_note | Recent note documents 1 fall(s) in the past year with frailty/gait concerns.
clinical_flag
Urine ACR overdue
dismissed | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
note
SOAP note
BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance.
note
SOAP note
Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed.
appointment
periodic health review
completed
report
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
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.
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.
report
Screening
PSA discussed - shared decision
appointment
preventive care recall
no_show
appointment
chronic disease review
completed
SOAP note
BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance.
SOAP note
Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed.
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.
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.
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
Screening
PSA discussed - shared decision
Smoking Status
never smoker
2026-05-29Hba1c
7.4 %
2026-05-12Diastolic Bp
91 mmHg
2026-03-17Systolic Bp
155 mmHg
2026-03-17Egfr
85 mL/min/1.73m2
2025-11-18Ldl Cholesterol
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: frailty_falls falls_review_due medium new Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | Clinical note: SOAP note Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | Clinical 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. | 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=outreach_planned | imported | next review=2026-06-23 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient. | |
clinical_flag | Falls risk review due | new | medium | clinical_note | Recent note documents 1 fall(s) in the past year with frailty/gait concerns. | |
clinical_flag | Urine ACR overdue | dismissed | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window. | |
care_element | smoking_status | never smoker | |
note | SOAP note | BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | |
care_element | hba1c | ||
note | SOAP note | Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | periodic health review | completed | |
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
care_element | egfr | ||
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 | ldl_cholesterol | ||
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 | albumin_creatinine_ratio | ||
report | Screening | PSA discussed - shared decision | |
care_element | cancer_screening | PSA discussed - shared decision | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | bmi | ||
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
appointment | preventive care recall | no_show | |
care_element | hba1c | ||
care_element | ldl_cholesterol | ||
appointment | chronic disease review | completed | |
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
appointment | medication renewal | no_show | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | fasting_glucose | ||
care_element | systolic_bp | ||
care_element | diastolic_bp |
2.3 mmol/L
2025-09-08Albumin Creatinine Ratio
38.8 mg/mmol
2025-04-02Cancer Screening
PSA discussed - shared decision
2024-12-30Diastolic Bp
83 mmHg
2024-07-25Systolic Bp
137 mmHg
2024-07-25Bmi
21.8 kg/m2
2024-06-27Ldl Cholesterol
3.5 mmol/L
2024-06-12Hba1c
7.8 %
2024-06-08Hba1c
7.5 %
2023-09-16Ldl Cholesterol
4.2 mmol/L
2023-06-03Ldl Cholesterol
3.8 mmol/L
2022-07-01Hba1c
8.2 %
2022-05-23Diastolic Bp
76 mmHg
2022-02-09Systolic Bp
135 mmHg
2022-02-09Fasting Glucose
10.6 mmol/L
2022-01-17Diastolic Bp
79 mmHg
2021-09-20Systolic Bp
129 mmHg
2021-09-20