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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: diabetes_prediabetes prediabetes_risk medium in_review Prediabetes range HbA1c Latest HbA1c 6.1% falls in the prediabetes range without a diabetes problem-li...
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
2026-03-09
Appointment or derived chart contact
Latest A1c
6.1 %
2023-09-19
Latest BP
145 mmHg / 76 mmHg
2025-03-16
Extracted signals
0
Optional text signals
Chart volume
25
4 notes, 0 reports
A compact view of what needs attention before opening the full imported record.
Review priority
2
active signal
s
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.
BP above target
Latest BP is 145 mmHg / 76 mmHg on 2025-03-16.
Active problems
2
Chronic neck pain
active
Major depressive disorder
active
Active medications
3
Hydromorphone
1 mg q6h PRN
Acetaminophen
1000 mg TID PRN
Oxycodone/acetaminophen
5/325 mg q6h PRN
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.
11, 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: OPIOID_MONITORING_DUE
status=needs_review | imported | outreach=sms 2026-04-02 16:50 | next review=2026-06-23 | Review evidence for Opioid monitoring review due; confirm appropriateness before contacting patient.
PHM saved action
PHM action: PREDIABETES_RISK
status=in_review | imported | outreach=phone 2026-03-25 16:15 | next review=2026-06-09 | 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 in_review Prediabetes range HbA1c Latest HbA1c 6.1% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Flag: chronic_pain_opioids opioid_monitoring_due high accepted Opioid monitoring review due Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documenta... | Clinical note: SOAP note Mental health review. PHQ-9 11, GAD-7 10. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status never smoker form | probable
phm_workflow
PHM action: OPIOID_MONITORING_DUE
status=needs_review | imported | outreach=sms 2026-04-02 16:50 | next review=2026-06-23 | Review evidence for Opioid monitoring review due; confirm appropriateness before contacting patient.
phm_workflow
PHM action: PREDIABETES_RISK
status=in_review | imported | outreach=phone 2026-03-25 16:15 | next review=2026-06-09 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient.
clinical_flag
Opioid monitoring review due
accepted | high | structured_fact | Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation.
clinical_flag
Prediabetes range HbA1c
in_review | medium | structured_fact | Latest HbA1c 6.1% falls in the prediabetes range without a diabetes problem-list diagnosis.
note
SOAP note
Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports variable energy. Plan: update labs/vitals and arrange follow-up as clinically indicated.
appointment
periodic health review
no_show
note
SOAP note
Mental health review. PHQ-9 11, GAD-7 10. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
note
SOAP note
Pain follow-up for chronic neck pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 8/10.
note
preventive care
HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented.
appointment
preventive care recall
completed
appointment
chronic disease review
completed
appointment
medication renewal
no_show
SOAP note
Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports variable energy. Plan: update labs/vitals and arrange follow-up as clinically indicated.
SOAP note
Mental health review. PHQ-9 11, GAD-7 10. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
SOAP note
Pain follow-up for chronic neck pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 8/10.
preventive care
HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented.
Opioid monitoring review due
Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation.
Prediabetes range HbA1c
Latest HbA1c 6.1% falls in the prediabetes range without a diabetes problem-list diagnosis.
Diastolic Bp
76 mmHg
2025-03-16Systolic Bp
145 mmHg
2025-03-16Smoking Status
never smoker
2025-03-05Diastolic Bp
83 mmHg
2024-07-28Systolic Bp
135 mmHg
2024-07-28Bmi
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: diabetes_prediabetes prediabetes_risk medium in_review Prediabetes range HbA1c Latest HbA1c 6.1% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Flag: chronic_pain_opioids opioid_monitoring_due high accepted Opioid monitoring review due Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documenta... | Clinical note: SOAP note Mental health review. PHQ-9 11, GAD-7 10. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status never smoker form | probable | |
phm_workflow | PHM action: OPIOID_MONITORING_DUE | status=needs_review | imported | outreach=sms 2026-04-02 16:50 | next review=2026-06-23 | Review evidence for Opioid monitoring review due; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: PREDIABETES_RISK | status=in_review | imported | outreach=phone 2026-03-25 16:15 | next review=2026-06-09 | Review evidence for Prediabetes range HbA1c; confirm appropriateness before contacting patient. | |
clinical_flag | Opioid monitoring review due | accepted | high | structured_fact | Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation. | |
clinical_flag | Prediabetes range HbA1c | in_review | medium | structured_fact | Latest HbA1c 6.1% falls in the prediabetes range without a diabetes problem-list diagnosis. | |
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports variable energy. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
appointment | periodic health review | no_show | |
note | SOAP note | Mental health review. PHQ-9 11, GAD-7 10. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | |
note | SOAP note | Pain follow-up for chronic neck pain. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 8/10. | |
note | preventive care | HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | smoking_status | never smoker | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | bmi | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | egfr | ||
care_element | hba1c | ||
appointment | preventive care recall | completed | |
care_element | hba1c | ||
appointment | chronic disease review | completed | |
appointment | medication renewal | no_show |
27.4 kg/m2
2024-07-22Diastolic Bp
70 mmHg
2024-07-09Systolic Bp
117 mmHg
2024-07-09Egfr
81 mL/min/1.73m2
2024-04-14Hba1c
6.1 %
2023-09-19Hba1c
6.4 %
2022-12-26