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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: dementia dementia_care_plan_due medium new Dementia care plan review Cognitive disorder documented; care plan, caregiver supports, medication safety, and adv...
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
2
New, in review, or accepted tasks
Last visit
2023-09-07
Appointment or derived chart contact
Latest A1c
No A1c
Missing structured value
Latest BP
115 mmHg / 73 mmHg
2026-05-06
Extracted signals
0
Optional text signals
Chart volume
27
4 notes, 0 reports
A compact view of what needs attention before opening the full imported record.
Review priority
1
active signal
2
0
0
Review these before relying on the imported record clinically.
Review needed
2 open flags
Open clinical review items need status, assignment, or closure.
Active problems
3
Frailty risk
active
Mild cognitive impairment
G31.84
active
Essential hypertension
I10
active
Active medications
3
Candesartan
8 mg daily
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.
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.
14, more source rows below
Latest narrative evidence, clipped for scanning.
Recent report headers and excerpts.
No reports imported
Audit view for imported records. Kept collapsed so the working chart remains usable.
PHM saved action
PHM action: FALLS_REVIEW_DUE
status=in_review | imported | next review=2026-07-17 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient.
PHM saved action
PHM action: DEMENTIA_CARE_PLAN_DUE
status=outreach_done | imported | next review=2026-07-02 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: dementia dementia_care_plan_due medium new Dementia care plan review Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. clinical_note | 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 uses cane. Medication list and home safety reviewed. | 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=in_review | imported | next review=2026-07-17 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient.
phm_workflow
PHM action: DEMENTIA_CARE_PLAN_DUE
status=outreach_done | imported | next review=2026-07-02 | Review evidence for Dementia care plan review; 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
Dementia care plan review
new | medium | clinical_note | Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed.
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 uses cane. Medication list and home safety reviewed.
note
SOAP note
Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
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.
appointment
same-day concern
completed
appointment
lab follow-up
completed
appointment
lab follow-up
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 uses cane. Medication list and home safety reviewed.
SOAP note
Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
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.
Falls risk review due
Recent note documents 1 fall(s) in the past year with frailty/gait concerns.
Dementia care plan review
Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed.
Smoking Status
never smoker
2026-05-27Diastolic Bp
73 mmHg
2026-05-06Systolic Bp
115 mmHg
2026-05-06Diastolic Bp
70 mmHg
2025-07-03Systolic Bp
138 mmHg
2025-07-03Bmi
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: dementia dementia_care_plan_due medium new Dementia care plan review Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. clinical_note | 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 uses cane. Medication list and home safety reviewed. | 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=in_review | imported | next review=2026-07-17 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: DEMENTIA_CARE_PLAN_DUE | status=outreach_done | imported | next review=2026-07-02 | Review evidence for Dementia care plan review; 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 | Dementia care plan review | new | medium | clinical_note | Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. | |
care_element | smoking_status | never smoker | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
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 uses cane. Medication list and home safety reviewed. | |
note | SOAP note | Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | bmi | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
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. | |
appointment | same-day concern | completed | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | lab follow-up | completed | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | lab follow-up | completed | |
care_element | systolic_bp | ||
care_element | diastolic_bp |
21.6 kg/m2
2025-06-27Diastolic Bp
76 mmHg
2024-06-22Systolic Bp
138 mmHg
2024-06-22Diastolic Bp
63 mmHg
2023-02-20Systolic Bp
139 mmHg
2023-02-20Diastolic Bp
71 mmHg
2022-08-06Systolic Bp
156 mmHg
2022-08-06Diastolic Bp
67 mmHg
2021-03-27Systolic Bp
122 mmHg
2021-03-27