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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 recurrent_falls high completed Recurrent falls risk Recent note documents 3 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: Flag: frailty_falls recurrent_falls high completed Recurrent falls risk Recent note documents 3 fall(s) in the past year with frailty/gait concerns. clinical_note...
Open review tasks
1
New, in review, or accepted tasks
Last visit
2025-03-11
Appointment or derived chart contact
Latest A1c
No A1c
Missing structured value
Latest BP
153 mmHg / 81 mmHg
2026-01-02
Extracted signals
0
Optional text signals
Chart volume
28
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 153 mmHg / 81 mmHg on 2026-01-02.
Active problems
4
Glaucoma suspect
active
Frailty risk
active
History of TIA/stroke
Z86.73
active
Essential hypertension
I10
active
Active medications
2
Apixaban
5 mg BID
Amlodipine
5 mg daily
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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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.
14, 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: REPEATED_BP_ABOVE_TARGET
status=needs_review | imported | outreach=phone 2026-05-02 15:50 | next review=2026-06-09 | Review evidence for Repeated BP above target; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: frailty_falls recurrent_falls high completed Recurrent falls risk Recent note documents 3 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | Clinical note: SOAP note BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | Problem: active: Frailty risk: {"id":"PROB00288","patient_id":"PAT0139","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2023-02-16","source":"note_extracted"} | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Flag: frailty_falls recurrent_falls high completed Recurrent falls risk Recent note documents 3 fall(s) in the past year with frailty/gait concerns. clinical_note | Care element: smoking_status never smoker form | probable
phm_workflow
PHM action: REPEATED_BP_ABOVE_TARGET
status=needs_review | imported | outreach=phone 2026-05-02 15:50 | next review=2026-06-09 | Review evidence for Repeated BP above target; confirm appropriateness before contacting patient.
clinical_flag
Recurrent falls risk
completed | high | clinical_note | Recent note documents 3 fall(s) in the past year with frailty/gait concerns.
clinical_flag
Repeated BP above target
new | high | structured_fact | Two recent BP readings are above target: 144/84 and 153/81 mmHg.
note
SOAP note
Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed.
note
SOAP note
BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance.
note
consult
History of TIA/stroke follow-up. Patient reports intermittent exertional dyspnea. Plan: continue guideline-oriented risk management and monitor labs.
report
Consult
Eye care report: glaucoma suspect reviewed. Follow-up interval documented; no urgent ocular change in this synthetic report.
report
Consult
Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
appointment
periodic health review
completed
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.
appointment
periodic health review
completed
appointment
chronic disease review
completed
SOAP note
Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed.
SOAP note
BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance.
consult
History of TIA/stroke follow-up. Patient reports intermittent exertional dyspnea. Plan: continue guideline-oriented risk management and monitor labs.
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.
Consult
Eye care report: glaucoma suspect reviewed. Follow-up interval documented; no urgent ocular change in this synthetic report.
Consult
Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
Smoking Status
never smoker
2026-02-15Diastolic Bp
81 mmHg
2026-01-02Systolic Bp
153 mmHg
2026-01-02Diastolic Bp
84 mmHg
2025-04-28Systolic Bp
144 mmHg
2025-04-28Bmi
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: frailty_falls recurrent_falls high completed Recurrent falls risk Recent note documents 3 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | Clinical note: SOAP note BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | Problem: active: Frailty risk: {"id":"PROB00288","patient_id":"PAT0139","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2023-02-16","source":"note_extracted"} | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Flag: frailty_falls recurrent_falls high completed Recurrent falls risk Recent note documents 3 fall(s) in the past year with frailty/gait concerns. clinical_note | Care element: smoking_status never smoker form | probable | |
phm_workflow | PHM action: REPEATED_BP_ABOVE_TARGET | status=needs_review | imported | outreach=phone 2026-05-02 15:50 | next review=2026-06-09 | Review evidence for Repeated BP above target; confirm appropriateness before contacting patient. | |
clinical_flag | Recurrent falls risk | completed | high | clinical_note | Recent note documents 3 fall(s) in the past year with frailty/gait concerns. | |
clinical_flag | Repeated BP above target | new | high | structured_fact | Two recent BP readings are above target: 144/84 and 153/81 mmHg. | |
note | SOAP note | Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and near fall on stairs. Medication list and home safety reviewed. | |
note | SOAP note | BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | |
care_element | smoking_status | never smoker | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
note | consult | History of TIA/stroke follow-up. Patient reports intermittent exertional dyspnea. Plan: continue guideline-oriented risk management and monitor labs. | |
report | Consult | Eye care report: glaucoma suspect reviewed. Follow-up interval documented; no urgent ocular change in this synthetic report. | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
report | Consult | Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed. | |
appointment | periodic health review | completed | |
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 | bmi | ||
care_element | egfr | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | periodic health review | completed | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | chronic disease review | completed | |
appointment | preventive care recall | no_show |
30.4 kg/m2
2024-09-10Egfr
88 mL/min/1.73m2
2024-02-01Diastolic Bp
84 mmHg
2024-01-14Systolic Bp
145 mmHg
2024-01-14Diastolic Bp
82 mmHg
2023-06-19Systolic Bp
123 mmHg
2023-06-19Diastolic Bp
82 mmHg
2022-06-24Systolic Bp
118 mmHg
2022-06-24