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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
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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: diabetes_prediabetes prediabetes_risk medium in_review Prediabetes range HbA1c Latest HbA1c 5.8% 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 former smoker form
membership needs review
Open review tasks
3
New, in review, or accepted tasks
Last visit
2025-05-28
Appointment or derived chart contact
Latest A1c
5.8 %
2025-05-25
Latest BP
124 mmHg / 80 mmHg
2026-05-01
Extracted signals
0
Optional text signals
Chart volume
45
6 notes, 2 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
Major depressive disorder
active
Chronic kidney disease stage 3a
N18
active
Coronary artery disease
I25.10
active
Essential hypertension
I10
active
Active medications
5
Venlafaxine XR
75 mg daily
Apixaban
5 mg BID
Candesartan
8 mg daily
Hydrochlorothiazide
12.5 mg daily
Ramipril
5 mg daily
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.
Recent chart, workflow, AI, cohort, and audit events shown in the user's local time.
31, 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=needs_review | imported | next review=2026-07-17 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
PHM saved action
PHM action: CKD_LOW_EGFR_REVIEW
status=outreach_planned | imported | next review=2026-06-16 | Review evidence for Reduced eGFR requires review; confirm appropriateness before contacting patient.
PHM saved action
PHM action: PREDIABETES_RISK
status=outreach_planned | imported | next review=2026-07-17 | 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 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Clinical note: SOAP note Mental health review. PHQ-9 4, GAD-7 9. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | Clinical note: SOAP note BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Care element: smoking_status former smoker form | probable
phm_workflow
PHM action: AGE_ELIGIBLE_SCREENING_MISSING
status=needs_review | imported | next review=2026-07-17 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
phm_workflow
PHM action: CKD_LOW_EGFR_REVIEW
status=outreach_planned | imported | next review=2026-06-16 | Review evidence for Reduced eGFR requires review; confirm appropriateness before contacting patient.
phm_workflow
PHM action: PREDIABETES_RISK
status=outreach_planned | imported | next review=2026-07-17 | Review evidence for Prediabetes range HbA1c; 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
Reduced eGFR requires review
new | medium | structured_fact | Latest eGFR 42.0 mL/min/1.73m2 requires medication and renal-risk review.
clinical_flag
Prediabetes range HbA1c
in_review | medium | structured_fact | Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis.
note
SOAP note
Mental health review. PHQ-9 4, GAD-7 9. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
note
preventive care
Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records.
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.
note
preventive care
HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented.
note
SOAP note
BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance.
report
Consult
Consult follow-up for Coronary artery disease. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed.
SOAP note
Mental health review. PHQ-9 4, GAD-7 9. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms.
preventive care
Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records.
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.
preventive care
HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented.
Consult
Consult follow-up for Coronary artery disease. 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.
Age-eligible screening missing
Patient appears age-eligible for preventive screening, but no recent screening completion evidence is present.
Reduced eGFR requires review
Latest eGFR 42.0 mL/min/1.73m2 requires medication and renal-risk review.
Prediabetes range HbA1c
Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis.
Albumin Creatinine Ratio
92.9 mg/mmol
2026-05-04Diastolic Bp
80 mmHg
2026-05-01Systolic Bp
124 mmHg
2026-05-01Diastolic Bp
80 mmHg
2025-11-24Systolic Bp
149 mmHg
2025-11-24Smoking Status
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 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis. structured_fact | Clinical note: SOAP note Mental health review. PHQ-9 4, GAD-7 9. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | Clinical note: SOAP note BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Care element: smoking_status former smoker form | probable | |
phm_workflow | PHM action: AGE_ELIGIBLE_SCREENING_MISSING | status=needs_review | imported | next review=2026-07-17 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: CKD_LOW_EGFR_REVIEW | status=outreach_planned | imported | next review=2026-06-16 | Review evidence for Reduced eGFR requires review; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: PREDIABETES_RISK | status=outreach_planned | imported | next review=2026-07-17 | Review evidence for Prediabetes range HbA1c; 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 | Reduced eGFR requires review | new | medium | structured_fact | Latest eGFR 42.0 mL/min/1.73m2 requires medication and renal-risk review. | |
clinical_flag | Prediabetes range HbA1c | in_review | medium | structured_fact | Latest HbA1c 5.8% falls in the prediabetes range without a diabetes problem-list diagnosis. | |
care_element | albumin_creatinine_ratio | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
note | SOAP note | Mental health review. PHQ-9 4, GAD-7 9. Sleep poor. No acute safety concern documented. Plan includes counselling resources, medication review, and follow-up interval based on symptoms. | |
note | preventive care | Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records. | |
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. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | smoking_status | former smoker | |
note | preventive care | HbA1c in prediabetes range. Discussed weight, activity, nutrition, sleep, and repeat testing. No confirmed diabetes diagnosis documented. | |
note | SOAP note | BP reviewed. Home readings variable. Reviewed sodium, adherence, and medication tolerance. | |
report | Consult | Consult follow-up for Coronary artery disease. Risk factor optimization, medication adherence, symptom surveillance, and return precautions reviewed. | |
report | Laboratory | Creatinine/eGFR and urine albumin-creatinine ratio reviewed for chronic kidney disease monitoring. | |
note | consult | Coronary artery disease follow-up. Patient reports no chest pain. Plan: continue guideline-oriented risk management and monitor labs. | |
appointment | periodic health review | completed | |
care_element | hba1c | ||
care_element | bmi | ||
care_element | egfr | ||
appointment | medication renewal | completed | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | egfr | ||
care_element | egfr | ||
care_element | hba1c | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | hba1c | ||
appointment | medication renewal | completed | |
care_element | egfr | ||
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | hba1c | ||
care_element | egfr | ||
care_element | diastolic_bp | ||
appointment | medication renewal | completed | |
care_element | systolic_bp | ||
appointment | periodic health review | no_show |
former smoker
2025-11-12Hba1c
5.8 %
2025-05-25Bmi
25.6 kg/m2
2025-04-22Egfr
42 mL/min/1.73m2
2025-04-02Diastolic Bp
83 mmHg
2024-12-22Systolic Bp
127 mmHg
2024-12-22Egfr
49 mL/min/1.73m2
2024-12-08Egfr
53 mL/min/1.73m2
2023-10-09Hba1c
5.7 %
2023-08-08Diastolic Bp
78 mmHg
2023-01-09Systolic Bp
113 mmHg
2023-01-09Hba1c
5.8 %
2022-12-21Egfr
58 mL/min/1.73m2
2022-07-25Diastolic Bp
81 mmHg
2022-06-22Systolic Bp
133 mmHg
2022-06-22Hba1c
5.9 %
2021-12-07Egfr
56 mL/min/1.73m2
2021-08-19Diastolic Bp
86 mmHg
2021-01-17Systolic Bp
145 mmHg
2021-01-17