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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 in_review Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note...
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 in_review Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note...
Open review tasks
5
New, in review, or accepted tasks
Last visit
2026-02-20
Appointment or derived chart contact
Latest A1c
8.3 %
2026-03-07
Latest BP
124 mmHg / 85 mmHg
2026-05-15
Extracted signals
0
Optional text signals
Chart volume
57
6 notes, 3 reports
A compact view of what needs attention before opening the full imported record.
Review priority
2
active signal
s
5
0
0
Review these before relying on the imported record clinically.
Review needed
5 open flags
Open clinical review items need status, assignment, or closure.
A1c above review threshold
Latest HbA1c is 8.3 % on 2026-03-07.
Active problems
5
Frailty risk
active
Major depressive disorder
active
Chronic kidney disease stage 3a
N18
active
History of TIA/stroke
Z86.73
active
Type 2 diabetes mellitus
E11
active
Active medications
3
Escitalopram
10 mg daily
Atorvastatin
40 mg daily
Empagliflozin
10 mg daily
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.
43, 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: INFLUENZA_RECALL_DUE
status=outreach_planned | imported | outreach=phone 2026-05-28 13:15 | next review=2026-07-02 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient.
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=needs_review | imported | next review=2026-07-02 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
PHM saved action
PHM action: MODERATE_SEVERE_SYMPTOM_SCORE
status=new | imported | next review=2026-06-09 | Review evidence for Elevated mental health symptom score; confirm appropriateness before contacting patient.
PHM saved action
PHM action: DIABETES_ACR_OVERDUE
status=outreach_planned | imported | next review=2026-07-17 | Review evidence for Urine ACR overdue; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: frailty_falls recurrent_falls high in_review 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 needs help with shopping. Medication list and home safety reviewed. | Clinical note: SOAP note Mental health review. PHQ-9 22, GAD-7 18. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | Clinical 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. | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Flag: frailty_falls recurrent_falls high in_review 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=outreach_planned | imported | outreach=phone 2026-05-28 13:15 | next review=2026-07-02 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient.
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=needs_review | imported | next review=2026-07-02 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
phm_workflow
PHM action: MODERATE_SEVERE_SYMPTOM_SCORE
status=new | imported | next review=2026-06-09 | Review evidence for Elevated mental health symptom score; confirm appropriateness before contacting patient.
phm_workflow
PHM action: DIABETES_ACR_OVERDUE
status=outreach_planned | imported | next review=2026-07-17 | Review evidence for Urine ACR overdue; confirm appropriateness before contacting patient.
clinical_flag
Pneumococcal immunization review
completed | medium | active_cohort_automation | Older adult with no pneumococcal immunization evidence in the synthetic chart.
clinical_flag
Influenza immunization recall
in_review | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window.
clinical_flag
Age-eligible screening missing
new | medium | clinical_note | Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present.
clinical_flag
Recurrent falls risk
in_review | high | clinical_note | Recent note documents 2 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 22 and GAD-7 18; follow-up priority should be reviewed.
clinical_flag
Urine ACR overdue
in_review | 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 8.3% suggests above-target glycemic control and needs clinician review.
SOAP note
Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and needs help with shopping. Medication list and home safety reviewed.
SOAP note
Mental health review. PHQ-9 22, GAD-7 18. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
consult
History of TIA/stroke follow-up. Patient reports leg discomfort with walking. Plan: continue guideline-oriented risk management and monitor labs.
preventive care
Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records.
Consult
Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
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.
Pneumococcal immunization review
Older adult with no pneumococcal immunization evidence in the synthetic chart.
Influenza immunization recall
No recent influenza immunization evidence within the synthetic seasonal window.
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 2 fall(s) in the past year with frailty/gait concerns.
Elevated mental health symptom score
Recent note documents PHQ-9 22 and GAD-7 18; follow-up priority should be reviewed.
Urine ACR overdue
Patient has diabetes and no recent urine ACR evidence within the synthetic monitoring window.
HbA1c above target
Latest HbA1c 8.3% suggests above-target glycemic control and needs clinician review.
Albumin Creatinine Ratio
92.7 mg/mmol
2026-05-25Egfr
51 mL/min/1.73m2
2026-05-18Diastolic Bp
85 mmHg
2026-05-15Systolic Bp
124 mmHg
2026-05-15Ldl Cholesterol
1.3 mmol/L
2026-03-23Hba1c
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: frailty_falls recurrent_falls high in_review 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 needs help with shopping. Medication list and home safety reviewed. | Clinical note: SOAP note Mental health review. PHQ-9 22, GAD-7 18. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | Clinical 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. | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Flag: frailty_falls recurrent_falls high in_review 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=outreach_planned | imported | outreach=phone 2026-05-28 13:15 | next review=2026-07-02 | Review evidence for Influenza immunization recall; confirm appropriateness before contacting patient. | |
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=needs_review | imported | next review=2026-07-02 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: MODERATE_SEVERE_SYMPTOM_SCORE | status=new | imported | next review=2026-06-09 | Review evidence for Elevated mental health symptom score; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: DIABETES_ACR_OVERDUE | status=outreach_planned | imported | next review=2026-07-17 | Review evidence for Urine ACR overdue; confirm appropriateness before contacting patient. | |
clinical_flag | Pneumococcal immunization review | completed | medium | active_cohort_automation | Older adult with no pneumococcal immunization evidence in the synthetic chart. | |
clinical_flag | Influenza immunization recall | in_review | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window. | |
clinical_flag | Age-eligible screening missing | new | medium | clinical_note | Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present. | |
clinical_flag | Recurrent falls risk | in_review | high | clinical_note | Recent note documents 2 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 22 and GAD-7 18; follow-up priority should be reviewed. | |
clinical_flag | Urine ACR overdue | in_review | 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 8.3% suggests above-target glycemic control and needs clinician review. | |
alert | Diabetes control flag: HbA1c above target | Generated from longitudinal lab trend. | |
care_element | albumin_creatinine_ratio | ||
care_element | egfr | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
note | SOAP note | Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and needs help with shopping. Medication list and home safety reviewed. | |
note | SOAP note | Mental health review. PHQ-9 22, GAD-7 18. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | |
note | consult | History of TIA/stroke follow-up. Patient reports leg discomfort with walking. Plan: continue guideline-oriented risk management and monitor labs. | |
care_element | ldl_cholesterol | ||
report | Consult | Consult follow-up for History of TIA/stroke. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed. | |
care_element | hba1c | ||
appointment | same-day concern | completed | |
note | preventive care | Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records. | |
report | Laboratory | Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring. | |
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
care_element | fasting_glucose | ||
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 | bmi | ||
care_element | ldl_cholesterol | ||
care_element | egfr | ||
appointment | same-day concern | completed | |
care_element | immunization | COVID-19 vaccine documented | |
care_element | hba1c | ||
care_element | smoking_status | never smoker | |
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. | |
care_element | fasting_glucose | ||
care_element | immunization | Influenza vaccine documented | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | egfr | ||
appointment | periodic health review | completed | |
care_element | hba1c | ||
care_element | egfr | ||
care_element | hba1c | ||
appointment | periodic health review | completed | |
care_element | hba1c | ||
care_element | egfr | ||
care_element | ldl_cholesterol | ||
care_element | fasting_glucose | ||
appointment | same-day concern | completed | |
appointment | medication renewal | completed | |
care_element | egfr | ||
care_element | hba1c |
8.3 %
2026-03-07Fasting Glucose
9.9 mmol/L
2025-12-10Bmi
18.9 kg/m2
2025-11-16Ldl Cholesterol
3.3 mmol/L
2025-07-16Egfr
66 mL/min/1.73m2
2025-07-13Immunization
COVID-19 vaccine documented
2025-06-07Hba1c
8.3 %
2025-03-04Smoking Status
never smoker
2025-02-16Fasting Glucose
6.5 mmol/L
2024-10-21Immunization
Influenza vaccine documented
2024-03-14Diastolic Bp
82 mmHg
2024-02-10Systolic Bp
130 mmHg
2024-02-10Egfr
49 mL/min/1.73m2
2024-02-09Hba1c
8.6 %
2024-01-13Egfr
51 mL/min/1.73m2
2023-12-14Hba1c
8.9 %
2023-09-10Hba1c
8.4 %
2022-10-19Egfr
57 mL/min/1.73m2
2022-09-14Ldl Cholesterol
2.1 mmol/L
2022-05-19Fasting Glucose
7.9 mmol/L
2022-04-27Egfr
57 mL/min/1.73m2
2021-10-10Hba1c
8.5 %
2021-07-23