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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.
1, current
Smoking / Lung Screening review cohort
Chart evidence: Care element: smoking_status current smoker form
membership needs review
No review task has been created from this cohort for this patient yet.
Open review tasks
4
New, in review, or accepted tasks
Last visit
2026-01-08
Appointment or derived chart contact
Latest A1c
9 %
2026-02-28
Latest BP
128 mmHg / 71 mmHg
2026-03-30
Extracted signals
0
Optional text signals
Chart volume
39
4 notes, 1 reports
A compact view of what needs attention before opening the full imported record.
Review priority
2
active signal
s
4
0
0
Review these before relying on the imported record clinically.
Review needed
4 open flags
Open clinical review items need status, assignment, or closure.
A1c above review threshold
Latest HbA1c is 9 % on 2026-02-28.
Active problems
3
Diabetic retinopathy
active
Chronic neck pain
active
Type 2 diabetes mellitus
E11
active
Active medications
5
Duloxetine
30 mg daily
Hydromorphone
1 mg q6h PRN
Acetaminophen
1000 mg TID PRN
Gliclazide MR
30 mg daily
Metformin
500 mg BID
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.
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.
25, 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: AGE_ELIGIBLE_SCREENING_MISSING
status=needs_review | imported | outreach=email 2026-05-31 12:30 | next review=2026-06-23 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
PHM saved action
PHM action: EYE_EXAM_OVERDUE
status=needs_review | imported | outreach=phone 2026-05-04 08:20 | next review=2026-08-01 | Review evidence for Eye exam evidence missing or overdue; confirm appropriateness before contacting patient.
PHM saved action
PHM action: OPIOID_MONITORING_DUE
status=needs_review | imported | next review=2026-06-09 | Review evidence for Opioid monitoring review due; confirm appropriateness before contacting patient.
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status current smoker form | probable
phm_workflow
PHM action: AGE_ELIGIBLE_SCREENING_MISSING
status=needs_review | imported | outreach=email 2026-05-31 12:30 | next review=2026-06-23 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
phm_workflow
PHM action: EYE_EXAM_OVERDUE
status=needs_review | imported | outreach=phone 2026-05-04 08:20 | next review=2026-08-01 | Review evidence for Eye exam evidence missing or overdue; confirm appropriateness before contacting patient.
phm_workflow
PHM action: OPIOID_MONITORING_DUE
status=needs_review | imported | next review=2026-06-09 | Review evidence for Opioid monitoring review due; confirm appropriateness before contacting patient.
clinical_flag
Influenza immunization recall
dismissed | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window.
clinical_flag
Age-eligible screening missing
new | medium | clinical_note | Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present.
clinical_flag
Eye exam evidence missing or overdue
in_review | medium | active_cohort_automation | Diabetic retinopathy is documented but no recent eye exam report is present in the synthetic chart.
clinical_flag
Opioid monitoring review due
accepted | high | structured_fact | Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation.
clinical_flag
Urine ACR overdue
completed | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
clinical_flag
HbA1c above target
in_review | high | structured_fact | Latest HbA1c 9.0% suggests above-target glycemic control and needs clinician review.
alert
Diabetes control flag: HbA1c above target
Generated from longitudinal lab trend.
note
SOAP note
Pain follow-up for chronic neck pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 6/10.
appointment
same-day concern
completed
note
SOAP note
T2DM review. Home glucose pattern mostly at target. Discussed nutrition, exercise, foot care, and medication adherence. Plan: repeat HbA1c and review cardiovascular/renal risk.
SOAP note
Pain follow-up for chronic neck pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 6/10.
SOAP note
T2DM review. Home glucose pattern mostly at target. 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.
preventive care
Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records.
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
Influenza immunization recall
No recent influenza immunization evidence within the synthetic seasonal window.
Age-eligible screening missing
Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present.
Eye exam evidence missing or overdue
Diabetic retinopathy is documented but no recent eye exam report is present in the synthetic chart.
Opioid monitoring review due
Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation.
Urine ACR overdue
Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
HbA1c above target
Latest HbA1c 9.0% suggests above-target glycemic control and needs clinician review.
Diastolic Bp
71 mmHg
2026-03-30Systolic Bp
128 mmHg
2026-03-30Ldl Cholesterol
3.6 mmol/L
2026-03-27Fasting Glucose
6.6 mmol/L
2026-03-15Hba1c
9 %
2026-02-28Bmi
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status current smoker form | probable | |
phm_workflow | PHM action: AGE_ELIGIBLE_SCREENING_MISSING | status=needs_review | imported | outreach=email 2026-05-31 12:30 | next review=2026-06-23 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: EYE_EXAM_OVERDUE | status=needs_review | imported | outreach=phone 2026-05-04 08:20 | next review=2026-08-01 | Review evidence for Eye exam evidence missing or overdue; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: OPIOID_MONITORING_DUE | status=needs_review | imported | next review=2026-06-09 | Review evidence for Opioid monitoring review due; confirm appropriateness before contacting patient. | |
clinical_flag | Influenza immunization recall | dismissed | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window. | |
clinical_flag | Age-eligible screening missing | new | medium | clinical_note | Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present. | |
clinical_flag | Eye exam evidence missing or overdue | in_review | medium | active_cohort_automation | Diabetic retinopathy is documented but no recent eye exam report is present in the synthetic chart. | |
clinical_flag | Opioid monitoring review due | accepted | high | structured_fact | Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation. | |
clinical_flag | Urine ACR overdue | completed | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window. | |
clinical_flag | HbA1c above target | in_review | high | structured_fact | Latest HbA1c 9.0% suggests above-target glycemic control and needs clinician review. | |
alert | Diabetes control flag: HbA1c above target | Generated from longitudinal lab trend. | |
note | SOAP note | Pain follow-up for chronic neck pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 6/10. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | ldl_cholesterol | ||
care_element | fasting_glucose | ||
care_element | hba1c | ||
care_element | bmi | ||
appointment | same-day concern | completed | |
note | SOAP note | T2DM review. Home glucose pattern mostly at target. Discussed nutrition, exercise, foot care, and medication adherence. Plan: repeat HbA1c and review cardiovascular/renal risk. | |
care_element | hba1c | ||
care_element | egfr | ||
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
care_element | fasting_glucose | ||
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 | smoking_status | current smoker | |
note | preventive care | Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records. | |
care_element | immunization | COVID-19 vaccine documented | |
care_element | immunization | Influenza vaccine documented | |
care_element | hba1c | ||
care_element | ldl_cholesterol | ||
care_element | fasting_glucose | ||
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
care_element | hba1c | ||
care_element | fasting_glucose | ||
appointment | periodic health review | completed | |
care_element | hba1c | ||
appointment | chronic disease review | completed |
24.3 kg/m2
2026-01-19Hba1c
8.9 %
2025-10-15Egfr
65 mL/min/1.73m2
2025-08-13Fasting Glucose
10.1 mmol/L
2025-06-11Smoking Status
current smoker
2025-03-14Immunization
COVID-19 vaccine documented
2024-12-09Immunization
Influenza vaccine documented
2024-05-13Hba1c
9 %
2024-05-09Ldl Cholesterol
2.6 mmol/L
2024-04-02Fasting Glucose
8.5 mmol/L
2024-02-24Ldl Cholesterol
3.6 mmol/L
2023-09-20Hba1c
8.9 %
2023-02-16Hba1c
8.6 %
2022-07-04Fasting Glucose
7.6 mmol/L
2022-01-19Hba1c
7.9 %
2021-05-04