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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.
2, current
Mental Health review cohort
Chart evidence: Clinical note: SOAP note T2DM review. Home glucose pattern often elevated fasting. Discussed nutrition, exercise, foot care, and medication adherence. Plan: repeat...
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
4
New, in review, or accepted tasks
Last visit
2026-04-22
Appointment or derived chart contact
Latest A1c
8.4 %
2026-03-18
Latest BP
146 mmHg / 87 mmHg
2026-05-28
Extracted signals
0
Optional text signals
Chart volume
54
4 notes, 3 reports
A compact view of what needs attention before opening the full imported record.
Review priority
3
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 8.4 % on 2026-03-18.
BP above target
Latest BP is 146 mmHg / 87 mmHg on 2026-05-28.
Active problems
5
Macular degeneration
active
Major depressive disorder
active
Chronic kidney disease stage 3a
N18
active
Essential hypertension
I10
active
Type 2 diabetes mellitus
E11
active
Active medications
4
Mirtazapine
15 mg HS
Hydrochlorothiazide
12.5 mg daily
Ramipril
5 mg daily
Semaglutide
0.5 mg weekly
No review task has been created from this cohort for this patient yet.
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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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Most recent values are summarized here so the timeline can stay readable.
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40, more source rows below
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Recent report headers and excerpts.
Audit view for imported records. Kept collapsed so the working chart remains usable.
PHM saved action
PHM action: INFLUENZA_RECALL_DUE
status=needs_review | imported | next review=2026-07-17 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient.
PHM saved action
PHM action: REPEATED_BP_ABOVE_TARGET
status=in_review | imported | outreach=email 2026-05-31 12:00 | next review=2026-06-16 | Review evidence for Repeated BP above target; confirm appropriateness before contacting patient.
PHM saved action
PHM action: UNCONTROLLED_HBA1C
status=new | imported | next review=2026-06-16 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient.
cohort_run
Cohort: Mental Health review cohort
completed | Chart evidence: 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. | Clinical note: SOAP note Mental health review. PHQ-9 12, GAD-7 13. Sleep fragmented. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | Clinical note: SOAP note BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | Clinical note: SOAP note Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports stable function. Plan: update labs/vitals and arrange follow-up as clinically indicated. | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status never smoker form | probable
phm_workflow
PHM action: INFLUENZA_RECALL_DUE
status=needs_review | imported | next review=2026-07-17 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient.
phm_workflow
PHM action: REPEATED_BP_ABOVE_TARGET
status=in_review | imported | outreach=email 2026-05-31 12:00 | next review=2026-06-16 | Review evidence for Repeated BP above target; confirm appropriateness before contacting patient.
phm_workflow
PHM action: UNCONTROLLED_HBA1C
status=new | imported | next review=2026-06-16 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient.
clinical_flag
Influenza immunization recall
new | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window.
clinical_flag
Repeated BP above target
new | high | structured_fact | Two recent BP readings are above target: 146/92 and 146/87 mmHg.
clinical_flag
Urine ACR overdue
new | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
clinical_flag
HbA1c above target
new | high | structured_fact | Latest HbA1c 8.4% suggests above-target glycemic control and needs clinician review.
alert
Diabetes control flag: HbA1c above target
Generated from longitudinal lab trend.
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.
appointment
chronic disease review
cancelled
note
SOAP note
Mental health review. PHQ-9 12, GAD-7 13. Sleep fragmented. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
note
SOAP note
BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance.
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
Mental health review. PHQ-9 12, GAD-7 13. Sleep fragmented. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
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 stable function. Plan: update labs/vitals and arrange follow-up as clinically indicated.
Consult
Eye care report: macular degeneration reviewed. Follow-up interval documented; no urgent ocular change in this synthetic report.
Laboratory
Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring.
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.
Repeated BP above target
Two recent BP readings are above target: 146/92 and 146/87 mmHg.
Urine ACR overdue
Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
HbA1c above target
Latest HbA1c 8.4% suggests above-target glycemic control and needs clinician review.
Diastolic Bp
87 mmHg
2026-05-28Systolic Bp
146 mmHg
2026-05-28Hba1c
8.4 %
2026-03-18Ldl Cholesterol
1.5 mmol/L
2026-03-10Fasting Glucose
8 mmol/L
2026-01-02Smoking Status
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Mental Health review cohort | completed | Chart evidence: 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. | Clinical note: SOAP note Mental health review. PHQ-9 12, GAD-7 13. Sleep fragmented. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | Clinical note: SOAP note BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | Clinical note: SOAP note Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports stable function. Plan: update labs/vitals and arrange follow-up as clinically indicated. | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status never smoker form | probable | |
phm_workflow | PHM action: INFLUENZA_RECALL_DUE | status=needs_review | imported | next review=2026-07-17 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: REPEATED_BP_ABOVE_TARGET | status=in_review | imported | outreach=email 2026-05-31 12:00 | next review=2026-06-16 | Review evidence for Repeated BP above target; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: UNCONTROLLED_HBA1C | status=new | imported | next review=2026-06-16 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient. | |
clinical_flag | Influenza immunization recall | new | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window. | |
clinical_flag | Repeated BP above target | new | high | structured_fact | Two recent BP readings are above target: 146/92 and 146/87 mmHg. | |
clinical_flag | Urine ACR overdue | new | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window. | |
clinical_flag | HbA1c above target | new | high | structured_fact | Latest HbA1c 8.4% suggests above-target glycemic control and needs clinician review. | |
alert | Diabetes control flag: HbA1c above target | Generated from longitudinal lab trend. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
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. | |
appointment | chronic disease review | cancelled | |
care_element | hba1c | ||
care_element | ldl_cholesterol | ||
care_element | fasting_glucose | ||
note | SOAP note | Mental health review. PHQ-9 12, GAD-7 13. Sleep fragmented. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | |
care_element | smoking_status | never smoker | |
care_element | albumin_creatinine_ratio | ||
note | SOAP note | BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | |
appointment | lab follow-up | no_show | |
report | Consult | Eye care report: macular degeneration reviewed. Follow-up interval documented; no urgent ocular change in this synthetic report. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | bmi | ||
report | Laboratory | Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring. | |
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
care_element | hba1c | ||
care_element | egfr | ||
care_element | fasting_glucose | ||
care_element | hba1c | ||
care_element | immunization | Influenza vaccine documented | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | ldl_cholesterol | ||
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports stable function. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
care_element | fasting_glucose | ||
care_element | hba1c | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | egfr | ||
care_element | ldl_cholesterol | ||
appointment | lab follow-up | cancelled | |
care_element | egfr | ||
care_element | fasting_glucose | ||
care_element | hba1c | ||
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
care_element | egfr | ||
appointment | medication renewal | no_show | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | lab follow-up | cancelled |
never smoker
2025-10-15Albumin Creatinine Ratio
58.2 mg/mmol
2025-10-14Diastolic Bp
92 mmHg
2025-05-11Systolic Bp
146 mmHg
2025-05-11Bmi
26.2 kg/m2
2025-04-20Hba1c
7.8 %
2025-02-18Egfr
46 mL/min/1.73m2
2024-12-17Fasting Glucose
7.1 mmol/L
2024-12-09Hba1c
8.1 %
2024-11-04Immunization
Influenza vaccine documented
2024-08-11Diastolic Bp
79 mmHg
2024-05-22Systolic Bp
129 mmHg
2024-05-22Ldl Cholesterol
2.5 mmol/L
2024-03-09Fasting Glucose
7.7 mmol/L
2023-09-20Hba1c
8.1 %
2023-06-25Diastolic Bp
79 mmHg
2023-06-21Systolic Bp
138 mmHg
2023-06-21Egfr
48 mL/min/1.73m2
2023-06-18Ldl Cholesterol
2.5 mmol/L
2023-05-25Egfr
49 mL/min/1.73m2
2022-10-12Fasting Glucose
8.8 mmol/L
2022-10-06Hba1c
7 %
2022-05-20Ldl Cholesterol
2.3 mmol/L
2022-01-15Hba1c
6.9 %
2021-12-03Egfr
55 mL/min/1.73m2
2021-09-10Diastolic Bp
79 mmHg
2021-03-11Systolic Bp
131 mmHg
2021-03-11