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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: frailty_falls falls_review_due medium accepted Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_no...
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
7
New, in review, or accepted tasks
Last visit
2024-09-05
Appointment or derived chart contact
Latest A1c
9.9 %
2026-02-11
Latest BP
153 mmHg / 81 mmHg
2026-02-25
Extracted signals
0
Optional text signals
Chart volume
68
7 notes, 3 reports
A compact view of what needs attention before opening the full imported record.
Review priority
3
active signal
s
7
0
0
Review these before relying on the imported record clinically.
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
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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.
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54, more source rows below
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PHM saved action
PHM action: POLYPHARMACY_REVIEW
status=new | imported | next review=2026-06-09 | Review evidence for Polypharmacy medication review; confirm appropriateness before contacting patient.
PHM saved action
PHM action: INFLUENZA_RECALL_DUE
status=new | imported | outreach=email 2026-04-10 16:15 | next review=2026-07-02 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient.
PHM saved action
PHM action: FALLS_REVIEW_DUE
status=in_review | imported | next review=2026-06-09 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient.
PHM saved action
PHM action: REPEATED_BP_ABOVE_TARGET
status=needs_review | imported | outreach=portal 2026-05-21 09:20 | next review=2026-08-01 | Review evidence for Repeated BP above target; confirm appropriateness before contacting patient.
PHM saved action
PHM action: DIABETES_ACR_OVERDUE
status=needs_review | imported | next review=2026-06-23 | Review evidence for Urine ACR overdue; confirm appropriateness before contacting patient.
PHM saved action
PHM action: UNCONTROLLED_HBA1C
status=needs_review | imported | outreach=email 2026-04-27 15:40 | next review=2026-07-17 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: frailty_falls falls_review_due medium accepted Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_note | Flag: dementia dementia_care_plan_due medium accepted Dementia care plan review Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. clinical_note | Clinical note: SOAP note Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed. | Clinical note: SOAP note BP reviewed. Home readings above target several mornings. 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: POLYPHARMACY_REVIEW
status=new | imported | next review=2026-06-09 | Review evidence for Polypharmacy medication review; confirm appropriateness before contacting patient.
phm_workflow
PHM action: INFLUENZA_RECALL_DUE
status=new | imported | outreach=email 2026-04-10 16:15 | next review=2026-07-02 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient.
phm_workflow
PHM action: FALLS_REVIEW_DUE
status=in_review | imported | next review=2026-06-09 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient.
phm_workflow
PHM action: REPEATED_BP_ABOVE_TARGET
status=needs_review | imported | outreach=portal 2026-05-21 09:20 | next review=2026-08-01 | Review evidence for Repeated BP above target; confirm appropriateness before contacting patient.
phm_workflow
PHM action: DIABETES_ACR_OVERDUE
status=needs_review | imported | next review=2026-06-23 | Review evidence for Urine ACR overdue; confirm appropriateness before contacting patient.
phm_workflow
PHM action: UNCONTROLLED_HBA1C
status=needs_review | imported | outreach=email 2026-04-27 15:40 | next review=2026-07-17 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient.
clinical_flag
Polypharmacy medication review
accepted | medium | structured_fact | 7 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed.
clinical_flag
Influenza immunization recall
new | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window.
clinical_flag
Age-eligible screening missing
dismissed | medium | clinical_note | Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present.
clinical_flag
Falls risk review due
accepted | medium | clinical_note | Recent note documents 1 fall(s) in the past year with frailty/gait concerns.
clinical_flag
Elevated mental health symptom score
dismissed | high | clinical_note | Recent note documents PHQ-9 12 and GAD-7 20; follow-up priority should be reviewed.
clinical_flag
Dementia care plan review
accepted | medium | clinical_note | Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed.
SOAP note
Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed.
SOAP note
BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance.
SOAP note
Mental health review. PHQ-9 12, GAD-7 20. Sleep adequate. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
SOAP note
Cognitive follow-up. Family reports missed bills. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
Laboratory
Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring.
Consult
Eye care report: glaucoma suspect reviewed. Follow-up interval documented; no urgent ocular change in this synthetic report.
Polypharmacy medication review
7 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed.
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.
Falls risk review due
Recent note documents 1 fall(s) in the past year with frailty/gait concerns.
Elevated mental health symptom score
Recent note documents PHQ-9 12 and GAD-7 20; follow-up priority should be reviewed.
Dementia care plan review
Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed.
Reduced eGFR requires review
Latest eGFR 43.0 mL/min/1.73m2 requires medication and renal-risk review.
Repeated BP above target
Two recent BP readings are above target: 153/87 and 153/81 mmHg.
Urine ACR overdue
Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
HbA1c above target
Latest HbA1c 9.9% suggests above-target glycemic control and needs clinician review.
Review needed
7 open flags
Open clinical review items need status, assignment, or closure.
A1c above review threshold
Latest HbA1c is 9.9 % on 2026-02-11.
BP above target
Latest BP is 153 mmHg / 81 mmHg on 2026-02-25.
Active problems
7
Glaucoma suspect
active
Frailty risk
active
Major depressive disorder
active
Vascular dementia
F03
active
Chronic kidney disease stage 3b
N18
active
Active medications
7
Escitalopram
10 mg daily
Donepezil
5 mg HS
Hydrochlorothiazide
12.5 mg daily
Ramipril
5 mg daily
Empagliflozin
Diastolic Bp
81 mmHg
2026-02-25Systolic Bp
153 mmHg
2026-02-25Hba1c
9.9 %
2026-02-11Egfr
66 mL/min/1.73m2
2026-02-02Ldl Cholesterol
3.9 mmol/L
2026-01-15Diastolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: frailty_falls falls_review_due medium accepted Falls risk review due Recent note documents 1 fall(s) in the past year with frailty/gait concerns. clinical_note | Flag: dementia dementia_care_plan_due medium accepted Dementia care plan review Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. clinical_note | Clinical note: SOAP note Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed. | Clinical note: SOAP note BP reviewed. Home readings above target several mornings. 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: POLYPHARMACY_REVIEW | status=new | imported | next review=2026-06-09 | Review evidence for Polypharmacy medication review; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: INFLUENZA_RECALL_DUE | status=new | imported | outreach=email 2026-04-10 16:15 | next review=2026-07-02 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: FALLS_REVIEW_DUE | status=in_review | imported | next review=2026-06-09 | Review evidence for Falls risk review due; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: REPEATED_BP_ABOVE_TARGET | status=needs_review | imported | outreach=portal 2026-05-21 09:20 | next review=2026-08-01 | Review evidence for Repeated BP above target; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: DIABETES_ACR_OVERDUE | status=needs_review | imported | next review=2026-06-23 | Review evidence for Urine ACR overdue; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: UNCONTROLLED_HBA1C | status=needs_review | imported | outreach=email 2026-04-27 15:40 | next review=2026-07-17 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient. | |
clinical_flag | Polypharmacy medication review | accepted | medium | structured_fact | 7 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed. | |
clinical_flag | Influenza immunization recall | new | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window. | |
clinical_flag | Age-eligible screening missing | dismissed | medium | clinical_note | Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present. | |
clinical_flag | Falls risk review due | accepted | medium | clinical_note | Recent note documents 1 fall(s) in the past year with frailty/gait concerns. | |
clinical_flag | Elevated mental health symptom score | dismissed | high | clinical_note | Recent note documents PHQ-9 12 and GAD-7 20; follow-up priority should be reviewed. | |
clinical_flag | Dementia care plan review | accepted | medium | clinical_note | Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. | |
clinical_flag | Reduced eGFR requires review | dismissed | medium | structured_fact | Latest eGFR 43.0 mL/min/1.73m2 requires medication and renal-risk review. | |
clinical_flag | Repeated BP above target | new | high | structured_fact | Two recent BP readings are above target: 153/87 and 153/81 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 9.9% suggests above-target glycemic control and needs clinician review. | |
alert | Diabetes control flag: HbA1c above target | Generated from longitudinal lab trend. | |
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
note | SOAP note | Falls review. Patient reports 1 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed. | |
report | Laboratory | Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | hba1c | ||
care_element | egfr | ||
care_element | ldl_cholesterol | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
note | SOAP note | BP reviewed. Home readings above target several mornings. Reviewed sodium, adherence, and medication tolerance. | |
note | SOAP note | Mental health review. PHQ-9 12, GAD-7 20. Sleep adequate. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | |
care_element | bmi | ||
note | SOAP note | Cognitive follow-up. Family reports missed bills. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | |
note | preventive care | Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records. | |
care_element | egfr | ||
note | SOAP note | T2DM review. Home glucose pattern variable. Discussed nutrition, exercise, foot care, and medication adherence. Plan: repeat HbA1c and review cardiovascular/renal risk. | |
care_element | albumin_creatinine_ratio | ||
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. | |
report | Consult | Eye care report: glaucoma suspect reviewed. Follow-up interval documented; no urgent ocular change in this synthetic report. | |
care_element | hba1c | ||
care_element | albumin_creatinine_ratio | ||
care_element | immunization | Pneumococcal vaccine documented | |
appointment | lab follow-up | cancelled | |
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | smoking_status | never smoker | |
care_element | fasting_glucose | ||
care_element | ldl_cholesterol | ||
care_element | egfr | ||
care_element | immunization | Influenza vaccine documented | |
care_element | ldl_cholesterol | ||
appointment | lab follow-up | completed | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | hba1c | ||
care_element | egfr | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | hba1c | ||
care_element | fasting_glucose | ||
care_element | ldl_cholesterol | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | egfr | ||
appointment | chronic disease review | completed | |
care_element | hba1c | ||
appointment | chronic disease review | booked |
10 mg daily
87 mmHg
2025-12-08Systolic Bp
153 mmHg
2025-12-08Bmi
32.4 kg/m2
2025-09-20Egfr
43 mL/min/1.73m2
2025-07-16Albumin Creatinine Ratio
70.1 mg/mmol
2025-06-06Hba1c
9.9 %
2025-02-02Albumin Creatinine Ratio
38.7 mg/mmol
2025-02-01Immunization
Pneumococcal vaccine documented
2024-12-06Hba1c
9 %
2024-08-25Diastolic Bp
74 mmHg
2024-08-03Systolic Bp
119 mmHg
2024-08-03Smoking Status
never smoker
2024-07-27Fasting Glucose
9.2 mmol/L
2024-07-06Ldl Cholesterol
3 mmol/L
2024-03-26Egfr
35 mL/min/1.73m2
2024-02-10Immunization
Influenza vaccine documented
2023-12-15Ldl Cholesterol
3.1 mmol/L
2023-11-09Diastolic Bp
78 mmHg
2023-04-08Systolic Bp
137 mmHg
2023-04-08Hba1c
8 %
2023-02-24Egfr
43 mL/min/1.73m2
2022-12-28Diastolic Bp
66 mmHg
2022-12-26Systolic Bp
126 mmHg
2022-12-26Hba1c
8.2 %
2022-11-11Fasting Glucose
10.4 mmol/L
2022-07-24Ldl Cholesterol
2.8 mmol/L
2022-03-17Diastolic Bp
81 mmHg
2021-12-05Systolic Bp
133 mmHg
2021-12-05Egfr
44 mL/min/1.73m2
2021-08-27Hba1c
8.2 %
2021-03-22