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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 accepted Dementia care plan review Cognitive disorder documented; care plan, caregiver supports, medication safety, an...
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 3 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
2026-05-08
Appointment or derived chart contact
Latest A1c
No A1c
Missing structured value
Latest BP
129 mmHg / 78 mmHg
2025-11-10
Extracted signals
0
Optional text signals
Chart volume
27
6 notes, 1 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
4
Frailty risk
active
Osteoarthritis of hip
M19.90
active
Alzheimer-type dementia
F03
active
Chronic obstructive pulmonary disease
J44.9
active
Active medications
3
Donepezil
5 mg HS
Tiotropium inhaler
18 mcg daily
Salbutamol inhaler
100 mcg 1-2 puffs q4h PRN
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.
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.
13, 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: AGE_ELIGIBLE_SCREENING_MISSING
status=new | imported | next review=2026-06-16 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
PHM saved action
PHM action: RECURRENT_FALLS
status=in_review | imported | next review=2026-06-09 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
PHM saved action
PHM action: DEMENTIA_CARE_PLAN_DUE
status=in_review | imported | next review=2026-06-16 | 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 accepted 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 3 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | Clinical note: SOAP note Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and needs help with shopping. Medication list and home safety reviewed. | 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 3 fall(s) in the past year with frailty/gait concerns. clinical_note | Care element: smoking_status former smoker form | probable
phm_workflow
PHM action: AGE_ELIGIBLE_SCREENING_MISSING
status=new | imported | next review=2026-06-16 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
phm_workflow
PHM action: RECURRENT_FALLS
status=in_review | imported | next review=2026-06-09 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
phm_workflow
PHM action: DEMENTIA_CARE_PLAN_DUE
status=in_review | imported | next review=2026-06-16 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient.
clinical_flag
Age-eligible screening missing
in_review | medium | clinical_note | Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present.
clinical_flag
Recurrent falls risk
new | high | clinical_note | Recent note documents 3 fall(s) in the past year with frailty/gait concerns.
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.
appointment
preventive care recall
completed
note
SOAP note
Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
note
SOAP note
COPD review. Symptoms include wheeze during viral illness. Inhaler technique reviewed. Exacerbation risk discussed.
note
SOAP note
Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and needs help with shopping. Medication list and home safety reviewed.
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.
note
preventive care
Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records.
SOAP note
Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports.
SOAP note
COPD review. Symptoms include wheeze during viral illness. Inhaler technique reviewed. Exacerbation risk discussed.
SOAP note
Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and needs help with shopping. Medication list and home safety reviewed.
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.
Laboratory
Spirometry: obstructive pattern compatible with COPD; post-bronchodilator values documented in scanned pulmonary function report.
Age-eligible screening missing
Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present.
Recurrent falls risk
Recent note documents 3 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
former smoker
2026-06-01Diastolic Bp
78 mmHg
2025-11-10Systolic Bp
129 mmHg
2025-11-10Diastolic Bp
78 mmHg
2025-07-26Systolic Bp
132 mmHg
2025-07-26Egfr
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: 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 | Flag: frailty_falls recurrent_falls high new Recurrent falls risk Recent note documents 3 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | Clinical note: SOAP note Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and needs help with shopping. Medication list and home safety reviewed. | 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 3 fall(s) in the past year with frailty/gait concerns. clinical_note | Care element: smoking_status former smoker form | probable | |
phm_workflow | PHM action: AGE_ELIGIBLE_SCREENING_MISSING | status=new | imported | next review=2026-06-16 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: RECURRENT_FALLS | status=in_review | imported | next review=2026-06-09 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: DEMENTIA_CARE_PLAN_DUE | status=in_review | imported | next review=2026-06-16 | Review evidence for Dementia care plan review; confirm appropriateness before contacting patient. | |
clinical_flag | Age-eligible screening missing | in_review | medium | clinical_note | Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present. | |
clinical_flag | Recurrent falls risk | new | high | clinical_note | Recent note documents 3 fall(s) in the past year with frailty/gait concerns. | |
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. | |
care_element | smoking_status | former smoker | |
appointment | preventive care recall | completed | |
note | SOAP note | Cognitive follow-up. Family reports wandering concern. Reviewed medication safety, driving/safety, caregiver stress, and community supports. | |
note | SOAP note | COPD review. Symptoms include wheeze during viral illness. Inhaler technique reviewed. Exacerbation risk discussed. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
note | SOAP note | Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and needs help with shopping. Medication list and home safety reviewed. | |
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. | |
note | preventive care | Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
note | SOAP note | MSK review: chronic hip pain with morning stiffness and crepitus, consistent with osteoarthritis pattern. Discussed activity modification, strengthening, topical/oral analgesia risks, imaging only if red flags or surgical planning. | |
care_element | egfr | ||
care_element | bmi | ||
appointment | same-day concern | completed | |
report | Laboratory | Spirometry: obstructive pattern compatible with COPD; post-bronchodilator values documented in scanned pulmonary function report. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
appointment | chronic disease review | completed |
64 mL/min/1.73m2
2024-09-25Bmi
20.2 kg/m2
2024-08-21Diastolic Bp
78 mmHg
2024-06-02Systolic Bp
128 mmHg
2024-06-02