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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 never smoker form
membership needs review
No review task has been created from this cohort for this patient yet.
Open review tasks
3
New, in review, or accepted tasks
Last visit
2026-02-14
Appointment or derived chart contact
Latest A1c
8 %
2026-05-05
Latest BP
123 mmHg / 72 mmHg
2025-10-17
Extracted signals
0
Optional text signals
Chart volume
42
3 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.
A1c above review threshold
Latest HbA1c is 8 % on 2026-05-05.
Active problems
4
Diabetic retinopathy
active
Vascular dementia
F03
active
Chronic kidney disease stage 3b
N18
active
Type 2 diabetes mellitus
E11
active
Active medications
3
Donepezil
5 mg HS
Metformin
500 mg BID
Metformin XR
1000 mg daily
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.
28, 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: EYE_EXAM_OVERDUE
status=needs_review | imported | next review=2026-07-02 | Review evidence for Eye exam evidence missing or overdue; confirm appropriateness before contacting patient.
PHM saved action
PHM action: CKD_LOW_EGFR_REVIEW
status=new | imported | outreach=phone 2026-04-23 15:15 | next review=2026-08-01 | Review evidence for Reduced eGFR requires review; confirm appropriateness before contacting patient.
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status never smoker form | probable
phm_workflow
PHM action: EYE_EXAM_OVERDUE
status=needs_review | imported | next review=2026-07-02 | Review evidence for Eye exam evidence missing or overdue; confirm appropriateness before contacting patient.
phm_workflow
PHM action: CKD_LOW_EGFR_REVIEW
status=new | imported | outreach=phone 2026-04-23 15:15 | next review=2026-08-01 | Review evidence for Reduced eGFR requires review; confirm appropriateness before contacting patient.
clinical_flag
Eye exam evidence missing or overdue
accepted | medium | active_cohort_automation | Diabetic retinopathy is documented but no recent eye exam report is present in the synthetic chart.
clinical_flag
Dementia care plan review
completed | 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
new | medium | structured_fact | Latest eGFR 40.0 mL/min/1.73m2 requires medication and renal-risk review.
clinical_flag
Urine ACR overdue
accepted | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
clinical_flag
HbA1c above target
completed | high | structured_fact | Latest HbA1c 8.0% suggests above-target glycemic control and needs clinician review.
alert
Diabetes control flag: HbA1c above target
Generated from longitudinal lab trend.
note
SOAP note
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
periodic health review
completed
report
Laboratory
Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring.
note
SOAP note
Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
report
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
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
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 recent family stress. Plan: update labs/vitals and arrange follow-up as clinically indicated.
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.
Eye exam evidence missing or overdue
Diabetic retinopathy is documented but no recent eye exam report is present in the synthetic chart.
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 40.0 mL/min/1.73m2 requires medication and renal-risk review.
Urine ACR overdue
Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
HbA1c above target
Latest HbA1c 8.0% suggests above-target glycemic control and needs clinician review.
Hba1c
8 %
2026-05-05Egfr
40 mL/min/1.73m2
2026-05-01Ldl Cholesterol
3.2 mmol/L
2026-04-27Fasting Glucose
6.7 mmol/L
2026-03-23Diastolic Bp
72 mmHg
2025-10-17Systolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status never smoker form | probable | |
phm_workflow | PHM action: EYE_EXAM_OVERDUE | status=needs_review | imported | next review=2026-07-02 | Review evidence for Eye exam evidence missing or overdue; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: CKD_LOW_EGFR_REVIEW | status=new | imported | outreach=phone 2026-04-23 15:15 | next review=2026-08-01 | Review evidence for Reduced eGFR requires review; confirm appropriateness before contacting patient. | |
clinical_flag | Eye exam evidence missing or overdue | accepted | medium | active_cohort_automation | Diabetic retinopathy is documented but no recent eye exam report is present in the synthetic chart. | |
clinical_flag | Dementia care plan review | completed | 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 | new | medium | structured_fact | Latest eGFR 40.0 mL/min/1.73m2 requires medication and renal-risk review. | |
clinical_flag | Urine ACR overdue | accepted | medium | active_cohort_automation | Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window. | |
clinical_flag | HbA1c above target | completed | high | structured_fact | Latest HbA1c 8.0% suggests above-target glycemic control and needs clinician review. | |
alert | Diabetes control flag: HbA1c above target | Generated from longitudinal lab trend. | |
care_element | hba1c | ||
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. | |
care_element | egfr | ||
care_element | ldl_cholesterol | ||
care_element | fasting_glucose | ||
appointment | periodic health review | completed | |
report | Laboratory | Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring. | |
care_element | hba1c | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | albumin_creatinine_ratio | ||
care_element | ldl_cholesterol | ||
note | SOAP note | Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | |
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
care_element | fasting_glucose | ||
care_element | egfr | ||
care_element | egfr | ||
care_element | albumin_creatinine_ratio | ||
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 | fasting_glucose | ||
care_element | bmi | ||
appointment | chronic disease review | completed | |
care_element | smoking_status | never smoker | |
care_element | hba1c | ||
care_element | fasting_glucose | ||
care_element | hba1c | ||
care_element | egfr | ||
care_element | fasting_glucose | ||
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
care_element | egfr | ||
care_element | hba1c | ||
appointment | medication renewal | completed |
123 mmHg
2025-10-17Hba1c
7.9 %
2025-10-17Albumin Creatinine Ratio
53.5 mg/mmol
2025-10-01Ldl Cholesterol
3.6 mmol/L
2025-09-09Fasting Glucose
6.8 mmol/L
2025-07-13Egfr
52 mL/min/1.73m2
2025-05-29Egfr
38 mL/min/1.73m2
2025-04-07Albumin Creatinine Ratio
21.4 mg/mmol
2025-01-08Fasting Glucose
8.6 mmol/L
2024-09-09Bmi
24.5 kg/m2
2024-09-04Smoking Status
never smoker
2024-08-06Hba1c
6.9 %
2024-01-02Fasting Glucose
10.3 mmol/L
2023-09-21Hba1c
7.1 %
2023-04-24Egfr
41 mL/min/1.73m2
2022-11-07Fasting Glucose
11 mmol/L
2022-10-14Ldl Cholesterol
1.9 mmol/L
2022-08-20Hba1c
6.7 %
2022-08-15Egfr
40 mL/min/1.73m2
2021-11-10Hba1c
6.8 %
2021-08-21