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Accepted chart labels
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.
2, current
Frailty / Falls review cohort
Chart evidence: Flag: diabetes_prediabetes prediabetes_risk medium accepted Prediabetes range HbA1c Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-lis...
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
3
New, in review, or accepted tasks
Last visit
2026-06-02
Appointment or derived chart contact
Latest A1c
5.8 %
2025-08-06
Latest BP
159 mmHg / 99 mmHg
2026-05-13
Extracted signals
0
Optional text signals
Chart volume
43
6 notes, 2 reports
A compact view of what needs attention before opening the full imported record.
Review priority
2
active signal
s
3
0
0
Review these before relying on the imported record clinically.
Review needed
3 open flags
Open clinical review items need status, assignment, or closure.
BP above target
Latest BP is 159 mmHg / 99 mmHg on 2026-05-13.
Active problems
4
Osteoarthritis of shoulder
M19.90
active
Breast cancer survivor
active
Chronic kidney disease stage 2 with albuminuria
N18
active
Essential hypertension
I10
active
Active medications
2
Hydrochlorothiazide
12.5 mg daily
Amlodipine
5 mg daily
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.
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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.
29, 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=new | imported | next review=2026-08-01 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
PHM saved action
PHM action: SURVIVORSHIP_PLAN_DUE
status=outreach_done | imported | outreach=sms 2026-05-04 16:15 | next review=2026-06-23 | Review evidence for Survivorship plan review due; confirm appropriateness before contacting patient.
PHM saved action
PHM action: PREDIABETES_RISK
status=outreach_planned | imported | outreach=email 2026-04-11 08:15 | next review=2026-08-01 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: diabetes_prediabetes prediabetes_risk medium accepted Prediabetes range HbA1c Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Clinical note: SOAP note BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance. | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status never smoker form | probable
phm_workflow
PHM action: AGE_ELIGIBLE_SCREENING_MISSING
status=new | imported | next review=2026-08-01 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
phm_workflow
PHM action: SURVIVORSHIP_PLAN_DUE
status=outreach_done | imported | outreach=sms 2026-05-04 16:15 | next review=2026-06-23 | Review evidence for Survivorship plan review due; confirm appropriateness before contacting patient.
phm_workflow
PHM action: PREDIABETES_RISK
status=outreach_planned | imported | outreach=email 2026-04-11 08:15 | next review=2026-08-01 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient.
clinical_flag
Age-eligible screening missing
accepted | medium | clinical_note | Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present.
clinical_flag
Survivorship plan review due
new | medium | report | Cancer history is active/imported; survivorship plan or surveillance schedule should be confirmed.
clinical_flag
Prediabetes range HbA1c
accepted | medium | structured_fact | Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis.
appointment
same-day concern
completed
note
preventive care
Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records.
note
SOAP note
MSK review: chronic shoulder pain with morning stiffness and crepitus, consistent with osteoarthritis pattern. Discussed activity modification, strengthening, topical/oral analgesia risks, imaging only if red flags or surgical planning.
note
preventive care
HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented.
note
SOAP note
BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance.
note
consult
Survivorship care reviewed for history of breast cancer survivor. Patient asks about surveillance schedule and late effects.
preventive care
Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records.
SOAP note
MSK review: chronic shoulder pain with morning stiffness and crepitus, consistent with osteoarthritis pattern. Discussed activity modification, strengthening, topical/oral analgesia risks, imaging only if red flags or surgical planning.
preventive care
HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented.
SOAP note
BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance.
Laboratory
Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring.
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.
Age-eligible screening missing
Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present.
Survivorship plan review due
Cancer history is active/imported; survivorship plan or surveillance schedule should be confirmed.
Prediabetes range HbA1c
Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis.
Diastolic Bp
99 mmHg
2026-05-13Systolic Bp
159 mmHg
2026-05-13Egfr
60 mL/min/1.73m2
2025-12-07Bmi
24.3 kg/m2
2025-09-19Hba1c
5.8 %
2025-08-06Diastolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: diabetes_prediabetes prediabetes_risk medium accepted Prediabetes range HbA1c Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Clinical note: SOAP note BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance. | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status never smoker form | probable | |
phm_workflow | PHM action: AGE_ELIGIBLE_SCREENING_MISSING | status=new | imported | next review=2026-08-01 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: SURVIVORSHIP_PLAN_DUE | status=outreach_done | imported | outreach=sms 2026-05-04 16:15 | next review=2026-06-23 | Review evidence for Survivorship plan review due; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: PREDIABETES_RISK | status=outreach_planned | imported | outreach=email 2026-04-11 08:15 | next review=2026-08-01 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient. | |
clinical_flag | Age-eligible screening missing | accepted | medium | clinical_note | Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present. | |
clinical_flag | Survivorship plan review due | new | medium | report | Cancer history is active/imported; survivorship plan or surveillance schedule should be confirmed. | |
clinical_flag | Prediabetes range HbA1c | accepted | medium | structured_fact | Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis. | |
appointment | same-day concern | completed | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
note | preventive care | Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records. | |
note | SOAP note | MSK review: chronic shoulder pain with morning stiffness and crepitus, consistent with osteoarthritis pattern. Discussed activity modification, strengthening, topical/oral analgesia risks, imaging only if red flags or surgical planning. | |
care_element | egfr | ||
note | preventive care | HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented. | |
care_element | bmi | ||
note | SOAP note | BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance. | |
note | consult | Survivorship care reviewed for history of breast cancer survivor. Patient asks about surveillance schedule and late effects. | |
care_element | hba1c | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | albumin_creatinine_ratio | ||
report | Laboratory | Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring. | |
care_element | smoking_status | never smoker | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | hba1c | ||
care_element | egfr | ||
appointment | periodic health review | no_show | |
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 recent family stress. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | egfr | ||
appointment | chronic disease review | booked | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | egfr | ||
care_element | egfr | ||
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | periodic health review | completed |
79 mmHg
2025-05-10Systolic Bp
122 mmHg
2025-05-10Albumin Creatinine Ratio
8.2 mg/mmol
2025-03-25Smoking Status
never smoker
2024-12-27Diastolic Bp
71 mmHg
2024-12-26Systolic Bp
112 mmHg
2024-12-26Hba1c
6.4 %
2024-08-05Egfr
65 mL/min/1.73m2
2024-06-05Diastolic Bp
77 mmHg
2023-06-26Systolic Bp
125 mmHg
2023-06-26Egfr
67 mL/min/1.73m2
2023-04-13Diastolic Bp
69 mmHg
2022-09-16Systolic Bp
144 mmHg
2022-09-16Egfr
68 mL/min/1.73m2
2022-09-12Egfr
71 mL/min/1.73m2
2021-12-19Hba1c
6.1 %
2021-09-03Diastolic Bp
84 mmHg
2021-01-09Systolic Bp
143 mmHg
2021-01-09