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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: dementia dementia_care_plan_due medium in_review Dementia care plan review Cognitive disorder documented; care plan, caregiver supports, medication safety, a...
membership needs review
No review task has been created from this cohort for this patient yet.
Smoking / Lung Screening review cohort
Chart evidence: Flag: frailty_falls recurrent_falls high new Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Care...
Open review tasks
3
New, in review, or accepted tasks
Last visit
2026-03-15
Appointment or derived chart contact
Latest A1c
4.9 %
2024-06-26
Latest BP
123 mmHg / 82 mmHg
2026-03-30
Extracted signals
0
Optional text signals
Chart volume
30
3 notes, 0 reports
A compact view of what needs attention before opening the full imported record.
Review priority
1
active signal
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.
Active problems
2
Frailty risk
active
Mild cognitive impairment
G31.84
active
Active medications
0
No active medications imported.
membership needs review
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.
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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.
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16, 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: INFLUENZA_RECALL_DUE
status=in_review | imported | next review=2026-07-17 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient.
PHM saved action
PHM action: RECURRENT_FALLS
status=new | imported | next review=2026-07-02 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
PHM saved action
PHM action: DEMENTIA_CARE_PLAN_DUE
status=outreach_done | imported | outreach=phone 2026-03-01 12:20 | 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 in_review 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 recurrent_falls high new Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed. | Clinical note: SOAP note Cognitive follow-up. Family reports more repetition. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Flag: frailty_falls recurrent_falls high new Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Care element: smoking_status never smoker form | probable
phm_workflow
PHM action: INFLUENZA_RECALL_DUE
status=in_review | imported | next review=2026-07-17 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient.
phm_workflow
PHM action: RECURRENT_FALLS
status=new | imported | next review=2026-07-02 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
phm_workflow
PHM action: DEMENTIA_CARE_PLAN_DUE
status=outreach_done | imported | outreach=phone 2026-03-01 12:20 | next review=2026-07-02 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient.
clinical_flag
Influenza immunization recall
accepted | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window.
clinical_flag
Recurrent falls risk
new | high | clinical_note | Recent note documents 2 fall(s) in the past year with frailty/gait concerns.
clinical_flag
Dementia care plan review
in_review | medium | clinical_note | Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed.
appointment
chronic disease review
completed
note
SOAP note
Falls review. Patient reports 2 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 more repetition. 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 improving symptoms. Plan: update labs/vitals and arrange follow-up as clinically indicated.
appointment
medication renewal
completed
appointment
preventive care recall
completed
SOAP note
Falls review. Patient reports 2 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 more repetition. 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 improving symptoms. Plan: update labs/vitals and arrange follow-up as clinically indicated.
Influenza immunization recall
No recent influenza immunization evidence within the synthetic seasonal window.
Recurrent falls risk
Recent note documents 2 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.
Diastolic Bp
82 mmHg
2026-03-30Systolic Bp
123 mmHg
2026-03-30Diastolic Bp
77 mmHg
2025-12-02Systolic Bp
131 mmHg
2025-12-02Egfr
66 mL/min/1.73m2
2025-09-25Immunization
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: dementia dementia_care_plan_due medium in_review 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 recurrent_falls high new Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and uses cane. Medication list and home safety reviewed. | Clinical note: SOAP note Cognitive follow-up. Family reports more repetition. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Flag: frailty_falls recurrent_falls high new Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Care element: smoking_status never smoker form | probable | |
phm_workflow | PHM action: INFLUENZA_RECALL_DUE | status=in_review | imported | next review=2026-07-17 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: RECURRENT_FALLS | status=new | imported | next review=2026-07-02 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: DEMENTIA_CARE_PLAN_DUE | status=outreach_done | imported | outreach=phone 2026-03-01 12:20 | next review=2026-07-02 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient. | |
clinical_flag | Influenza immunization recall | accepted | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window. | |
clinical_flag | Recurrent falls risk | new | high | clinical_note | Recent note documents 2 fall(s) in the past year with frailty/gait concerns. | |
clinical_flag | Dementia care plan review | in_review | medium | clinical_note | Cognitive disorder documented; care plan, caregiver supports, medication safety, and advance-care planning should be reviewed. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | chronic disease review | completed | |
note | SOAP note | Falls review. Patient reports 2 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 more repetition. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | egfr | ||
care_element | immunization | Pneumococcal vaccine documented | |
care_element | smoking_status | never smoker | |
care_element | immunization | Influenza vaccine documented | |
care_element | bmi | ||
care_element | hba1c | ||
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports improving symptoms. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
appointment | medication renewal | completed | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | preventive care recall | completed | |
care_element | immunization | COVID-19 vaccine documented | |
appointment | medication renewal | cancelled | |
appointment | chronic disease review | completed | |
appointment | chronic disease review | no_show |
Pneumococcal vaccine documented
2025-07-21Smoking Status
never smoker
2025-05-25Immunization
Influenza vaccine documented
2025-02-07Bmi
29.4 kg/m2
2024-09-17Hba1c
4.9 %
2024-06-26Diastolic Bp
74 mmHg
2023-12-11Systolic Bp
118 mmHg
2023-12-11Immunization
COVID-19 vaccine documented
2023-09-16