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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 accepted 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 accepted Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note |...
Open review tasks
2
New, in review, or accepted tasks
Last visit
2026-04-12
Appointment or derived chart contact
Latest A1c
No A1c
Missing structured value
Latest BP
126 mmHg / 80 mmHg
2026-01-18
Extracted signals
0
Optional text signals
Chart volume
30
5 notes, 1 reports
A compact view of what needs attention before opening the full imported record.
Review priority
1
active signal
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.
Active problems
3
Frailty risk
active
Chronic obstructive pulmonary disease
J44.9
active
Essential hypertension
I10
active
Active medications
3
Tiotropium inhaler
18 mcg daily
Salbutamol inhaler
100 mcg 1-2 puffs q4h PRN
Ramipril
5 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.
16, 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=2026-07-17 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
PHM saved action
PHM action: RECURRENT_FALLS
status=new | imported | outreach=phone 2026-04-01 11:10 | next review=2026-06-23 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
cohort_run
Cohort: Frailty / Falls review cohort
completed | Chart evidence: Flag: frailty_falls recurrent_falls high accepted Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance. | Clinical note: SOAP note Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed. | Problem: active: Frailty risk: {"id":"PROB00573","patient_id":"PAT0274","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2018-10-11","source":"problem_list"} | probable
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Flag: frailty_falls recurrent_falls high accepted 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: AGE_ELIGIBLE_SCREENING_MISSING
status=outreach_planned | imported | next review=2026-07-17 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient.
phm_workflow
PHM action: RECURRENT_FALLS
status=new | imported | outreach=phone 2026-04-01 11:10 | next review=2026-06-23 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient.
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
accepted | high | clinical_note | Recent note documents 2 fall(s) in the past year with frailty/gait concerns.
appointment
same-day concern
completed
note
SOAP note
BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance.
appointment
periodic health review
completed
note
SOAP note
Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed.
note
SOAP note
COPD review. Symptoms include stable exertional dyspnea. Inhaler technique reviewed. Exacerbation risk discussed.
note
preventive care
Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records.
report
Laboratory
Spirometry: obstructive pattern compatible with COPD; post-bronchodilator values documented in scanned pulmonary function report.
appointment
same-day concern
completed
SOAP note
BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance.
SOAP note
Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed.
SOAP note
COPD review. Symptoms include stable exertional dyspnea. Inhaler technique reviewed. Exacerbation risk discussed.
preventive care
Preventive care review: age-eligible cancer screening discussed. No completed screening result found in imported records.
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 2 fall(s) in the past year with frailty/gait concerns.
Diastolic Bp
80 mmHg
2026-01-18Systolic Bp
126 mmHg
2026-01-18Diastolic Bp
84 mmHg
2025-11-14Systolic Bp
130 mmHg
2025-11-14Diastolic Bp
73 mmHg
2024-12-21Systolic Bp
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Frailty / Falls review cohort | completed | Chart evidence: Flag: frailty_falls recurrent_falls high accepted Recurrent falls risk Recent note documents 2 fall(s) in the past year with frailty/gait concerns. clinical_note | Clinical note: SOAP note BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance. | Clinical note: SOAP note Falls review. Patient reports 2 fall(s) in the past year, gait speed reduced, and fear of falling. Medication list and home safety reviewed. | Problem: active: Frailty risk: {"id":"PROB00573","patient_id":"PAT0274","description":"Frailty risk","code":null,"code_system":"custom","status":"active","onset_date":"2018-10-11","source":"problem_list"} | probable | |
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Flag: frailty_falls recurrent_falls high accepted 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: AGE_ELIGIBLE_SCREENING_MISSING | status=outreach_planned | imported | next review=2026-07-17 | Review evidence for Age-eligible screening missing; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: RECURRENT_FALLS | status=new | imported | outreach=phone 2026-04-01 11:10 | next review=2026-06-23 | Review evidence for Recurrent falls risk; confirm appropriateness before contacting patient. | |
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 | accepted | high | clinical_note | Recent note documents 2 fall(s) in the past year with frailty/gait concerns. | |
appointment | same-day concern | completed | |
note | SOAP note | BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance. | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | periodic health review | completed | |
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 fear of falling. Medication list and home safety reviewed. | |
note | SOAP note | COPD review. Symptoms include stable exertional dyspnea. Inhaler technique reviewed. Exacerbation risk discussed. | |
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 | ||
care_element | bmi | ||
report | Laboratory | Spirometry: obstructive pattern compatible with COPD; post-bronchodilator values documented in scanned pulmonary function report. | |
appointment | same-day concern | completed | |
care_element | smoking_status | never smoker | |
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. | |
appointment | preventive care recall | completed | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | lab follow-up | booked | |
appointment | lab follow-up | completed |
117 mmHg
2024-12-21Bmi
18.8 kg/m2
2024-11-04Smoking Status
never smoker
2024-07-30Diastolic Bp
74 mmHg
2022-11-01Systolic Bp
117 mmHg
2022-11-01Diastolic Bp
79 mmHg
2021-05-21Systolic Bp
127 mmHg
2021-05-21