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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: 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 | Clin...
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
2026-05-05
Appointment or derived chart contact
Latest A1c
No A1c
Missing structured value
Latest BP
115 mmHg / 82 mmHg
2024-05-31
Extracted signals
0
Optional text signals
Chart volume
26
5 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
3
Frailty risk
active
Major depressive disorder
active
Atrial fibrillation
I48
active
Active medications
1
Apixaban
5 mg BID
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.
12, 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=outreach_planned | imported | next review=2026-08-01 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
PHM saved action
PHM action: MODERATE_SEVERE_SYMPTOM_SCORE
status=needs_review | imported | next review=2026-06-16 | Review evidence for Elevated mental health symptom score; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls 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 | Clinical note: SOAP note Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed. | Clinical note: SOAP note Mental health review. PHQ-9 15, GAD-7 6. Sleep adequate. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | Problem: active: Frailty risk: {"id":"PROB00079","patient_id":"PAT0037","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2016-11-18","source":"problem_list"} | 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 never smoker form | probable
phm_workflow
PHM action: AGE_ELIGIBLE_SCREENING_MISSING
status=outreach_planned | imported | next review=2026-08-01 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
phm_workflow
PHM action: MODERATE_SEVERE_SYMPTOM_SCORE
status=needs_review | imported | next review=2026-06-16 | Review evidence for Elevated mental health symptom score; 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
Elevated mental health symptom score
new | high | clinical_note | Recent note documents PHQ-9 15 and GAD-7 6; follow-up priority should be reviewed.
appointment
lab follow-up
completed
note
SOAP note
Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed.
note
SOAP note
Mental health review. PHQ-9 15, GAD-7 6. Sleep adequate. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
note
SOAP note
Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports no acute concern. Plan: update labs/vitals and arrange follow-up as clinically indicated.
note
consult
Atrial fibrillation follow-up. Patient reports leg discomfort with walking. Plan: continue guideline-oriented risk management and monitor labs.
note
preventive care
Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records.
appointment
chronic disease review
completed
SOAP note
Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed.
SOAP note
Mental health review. PHQ-9 15, GAD-7 6. Sleep adequate. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
SOAP note
Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports no acute concern. Plan: update labs/vitals and arrange follow-up as clinically indicated.
consult
Atrial fibrillation follow-up. Patient reports leg discomfort with walking. Plan: continue guideline-oriented risk management and monitor labs.
Consult
Consult follow-up for Atrial fibrillation. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
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.
Elevated mental health symptom score
Recent note documents PHQ-9 15 and GAD-7 6; follow-up priority should be reviewed.
Smoking Status
never smoker
2024-10-30Bmi
20.7 kg/m2
2024-06-18Diastolic Bp
82 mmHg
2024-05-31Systolic Bp
115 mmHg
2024-05-31Diastolic Bp
65 mmHg
2024-04-19Systolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls 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 | Clinical note: SOAP note Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed. | Clinical note: SOAP note Mental health review. PHQ-9 15, GAD-7 6. Sleep adequate. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | Problem: active: Frailty risk: {"id":"PROB00079","patient_id":"PAT0037","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2016-11-18","source":"problem_list"} | 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 never smoker form | probable | |
phm_workflow | PHM action: AGE_ELIGIBLE_SCREENING_MISSING | status=outreach_planned | imported | next review=2026-08-01 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: MODERATE_SEVERE_SYMPTOM_SCORE | status=needs_review | imported | next review=2026-06-16 | Review evidence for Elevated mental health symptom score; 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 | Elevated mental health symptom score | new | high | clinical_note | Recent note documents PHQ-9 15 and GAD-7 6; follow-up priority should be reviewed. | |
appointment | lab follow-up | completed | |
note | SOAP note | Falls review. Patient reports 3 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed. | |
note | SOAP note | Mental health review. PHQ-9 15, GAD-7 6. Sleep adequate. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | |
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports no acute concern. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
note | consult | Atrial fibrillation follow-up. Patient reports leg discomfort with walking. Plan: continue guideline-oriented risk management and monitor labs. | |
note | preventive care | Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records. | |
appointment | chronic disease review | completed | |
report | Consult | Consult follow-up for Atrial fibrillation. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed. | |
care_element | smoking_status | never smoker | |
care_element | bmi | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | egfr | ||
appointment | lab follow-up | completed | |
appointment | medication renewal | completed | |
appointment | chronic disease review | completed | |
appointment | medication renewal | completed |
131 mmHg
2024-04-19Egfr
70 mL/min/1.73m2
2024-03-11