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Cohort memberships
Patient-list membership from saved cohort runs. These are source lists, not task status or accepted chart labels.
1, current
Smoking / Lung Screening review cohort
Chart evidence: Flag: copd copd_recurrent_exacerbation high new Recurrent COPD exacerbation pattern Multiple COPD-related visits/exacerbation language identified within the recent...
membership needs review
No review task has been created from this cohort for this patient yet.
Open review tasks
4
New, in review, or accepted tasks
Last visit
2023-05-20
Appointment or derived chart contact
Latest A1c
8.9 %
2026-04-15
Latest BP
112 mmHg / 87 mmHg
2026-03-24
Extracted signals
0
Optional text signals
Chart volume
57
7 notes, 2 reports
A compact view of what needs attention before opening the full imported record.
Review priority
2
active signal
s
4
0
0
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0, selected
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Saved population-health queue work for this patient: calls, recalls, flags, snoozes, exclusions, and completions.
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43, more source rows below
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Audit view for imported records. Kept collapsed so the working chart remains usable.
PHM saved action
PHM action: ASTHMA_CONTROLLER_REVIEW
status=needs_review | imported | next review=2026-07-17 | Review evidence for Asthma controller therapy review; confirm appropriateness before contacting patient.
PHM saved action
PHM action: COPD_RECURRENT_EXACERBATION
status=needs_review | imported | next review=2026-08-01 | Review evidence for Recurrent COPD exacerbation pattern; confirm appropriateness before contacting patient.
PHM saved action
PHM action: UNCONTROLLED_HBA1C
status=new | imported | next review=2026-06-16 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient.
cohort_run
Cohort: Smoking / Lung Screening review cohort
completed | Chart evidence: Flag: copd copd_recurrent_exacerbation high new Recurrent COPD exacerbation pattern Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period. clinical_note | Care element: smoking_status current smoker form | probable
phm_workflow
PHM action: ASTHMA_CONTROLLER_REVIEW
status=needs_review | imported | next review=2026-07-17 | Review evidence for Asthma controller therapy review; confirm appropriateness before contacting patient.
phm_workflow
PHM action: COPD_RECURRENT_EXACERBATION
status=needs_review | imported | next review=2026-08-01 | Review evidence for Recurrent COPD exacerbation pattern; confirm appropriateness before contacting patient.
phm_workflow
PHM action: UNCONTROLLED_HBA1C
status=new | imported | next review=2026-06-16 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient.
clinical_flag
Polypharmacy medication review
dismissed | medium | structured_fact | 9 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed.
clinical_flag
Influenza immunization recall
dismissed | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window.
clinical_flag
Opioid monitoring review due
new | high | structured_fact | Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation.
clinical_flag
Asthma controller therapy review
new | medium | clinical_note | Asthma symptoms or reliever pattern suggest controller therapy/adherence should be reviewed.
clinical_flag
Recurrent COPD exacerbation pattern
new | high | clinical_note | Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period.
clinical_flag
HbA1c above target
new | high | structured_fact | Latest HbA1c 8.9% suggests above-target glycemic control and needs clinician review.
alert
Diabetes control flag: HbA1c above target
Generated from longitudinal lab trend.
note
SOAP note
BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance.
note
SOAP note
COPD review. Symptoms include wheeze during viral illness. Inhaler technique reviewed. Exacerbation risk discussed.
note
SOAP note
Pain follow-up for fibromyalgia. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 4/10.
SOAP note
BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance.
SOAP note
COPD review. Symptoms include wheeze during viral illness. Inhaler technique reviewed. Exacerbation risk discussed.
SOAP note
Pain follow-up for fibromyalgia. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 4/10.
SOAP note
T2DM review. Home glucose pattern limited due to missed checks. Discussed nutrition, exercise, foot care, and medication adherence. Plan: repeat HbA1c and review cardiovascular/renal risk.
Laboratory
HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up.
Laboratory
Spirometry: obstructive pattern compatible with COPD; post-bronchodilator values documented in scanned pulmonary function report.
Polypharmacy medication review
9 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed.
Influenza immunization recall
No recent influenza immunization evidence within the synthetic seasonal window.
Opioid monitoring review due
Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation.
Asthma controller therapy review
Asthma symptoms or reliever pattern suggest controller therapy/adherence should be reviewed.
Recurrent COPD exacerbation pattern
Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period.
HbA1c above target
Latest HbA1c 8.9% suggests above-target glycemic control and needs clinician review.
Review needed
4 open flags
Open clinical review items need status, assignment, or closure.
A1c above review threshold
Latest HbA1c is 8.9 % on 2026-04-15.
Active problems
5
Fibromyalgia
active
Asthma
J45.909
active
Chronic obstructive pulmonary disease
J44.9
active
Essential hypertension
I10
active
Type 2 diabetes mellitus
E11
active
Active medications
9
Celecoxib
100 mg BID PRN
Naproxen
500 mg BID PRN
Hydromorphone
1 mg q6h PRN
Salbutamol inhaler
100 mcg 1-2 puffs q4h PRN
Tiotropium inhaler
Albumin Creatinine Ratio
13.7 mg/mmol
2026-04-18Hba1c
8.9 %
2026-04-15Diastolic Bp
87 mmHg
2026-03-24Systolic Bp
112 mmHg
2026-03-24Ldl Cholesterol
2.4 mmol/L
2026-03-08Fasting Glucose
Date | Type | Title | Detail |
|---|---|---|---|
cohort_run | Cohort: Smoking / Lung Screening review cohort | completed | Chart evidence: Flag: copd copd_recurrent_exacerbation high new Recurrent COPD exacerbation pattern Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period. clinical_note | Care element: smoking_status current smoker form | probable | |
phm_workflow | PHM action: ASTHMA_CONTROLLER_REVIEW | status=needs_review | imported | next review=2026-07-17 | Review evidence for Asthma controller therapy review; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: COPD_RECURRENT_EXACERBATION | status=needs_review | imported | next review=2026-08-01 | Review evidence for Recurrent COPD exacerbation pattern; confirm appropriateness before contacting patient. | |
phm_workflow | PHM action: UNCONTROLLED_HBA1C | status=new | imported | next review=2026-06-16 | Review evidence for HbA1c above target; confirm appropriateness before contacting patient. | |
clinical_flag | Polypharmacy medication review | dismissed | medium | structured_fact | 9 active medications identified; medication reconciliation and deprescribing opportunities should be reviewed. | |
clinical_flag | Influenza immunization recall | dismissed | low | structured_fact | No recent influenza immunization evidence within the synthetic seasonal window. | |
clinical_flag | Opioid monitoring review due | new | high | structured_fact | Active opioid medication identified; verify treatment agreement, functional goals, dispense review, and urine drug screen documentation. | |
clinical_flag | Asthma controller therapy review | new | medium | clinical_note | Asthma symptoms or reliever pattern suggest controller therapy/adherence should be reviewed. | |
clinical_flag | Recurrent COPD exacerbation pattern | new | high | clinical_note | Multiple COPD-related visits/exacerbation language identified within the recent synthetic chart period. | |
clinical_flag | HbA1c above target | new | high | structured_fact | Latest HbA1c 8.9% suggests above-target glycemic control and needs clinician review. | |
alert | Diabetes control flag: HbA1c above target | Generated from longitudinal lab trend. | |
note | SOAP note | BP reviewed. Home readings not available. Reviewed sodium, adherence, and medication tolerance. | |
note | SOAP note | COPD review. Symptoms include wheeze during viral illness. Inhaler technique reviewed. Exacerbation risk discussed. | |
care_element | albumin_creatinine_ratio | ||
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
note | SOAP note | Pain follow-up for fibromyalgia. Function, sleep, mood, non-pharmacologic options, and medication risks reviewed. Pain score 4/10. | |
care_element | ldl_cholesterol | ||
care_element | fasting_glucose | ||
note | SOAP note | T2DM review. Home glucose pattern limited due to missed checks. Discussed nutrition, exercise, foot care, and medication adherence. Plan: repeat HbA1c and review cardiovascular/renal risk. | |
note | SOAP note | COPD review. Symptoms include increased cough and sputum. Inhaler technique reviewed. Exacerbation risk discussed. | |
care_element | smoking_status | current smoker | |
note | SOAP note | Asthma review. Symptoms: night cough twice weekly. Trigger avoidance and inhaler technique reviewed. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
report | Laboratory | HbA1c, fasting glucose, lipid panel, creatinine/eGFR, and urine ACR reviewed for diabetes follow-up. | |
care_element | egfr | ||
care_element | hba1c | ||
care_element | bmi | ||
care_element | ldl_cholesterol | ||
report | Laboratory | Spirometry: obstructive pattern compatible with COPD; post-bronchodilator values documented in scanned pulmonary function report. | |
care_element | hba1c | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
care_element | ldl_cholesterol | ||
care_element | immunization | Influenza vaccine documented | |
note | SOAP note | Follow-up visit. Medication list reviewed, allergies checked, and preventive care status discussed. Patient reports variable energy. Plan: update labs/vitals and arrange follow-up as clinically indicated. | |
care_element | systolic_bp | ||
care_element | diastolic_bp | ||
care_element | immunization | COVID-19 vaccine documented | |
care_element | immunization | Pneumococcal vaccine documented | |
care_element | fasting_glucose | ||
appointment | periodic health review | completed | |
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
care_element | hba1c | ||
care_element | fasting_glucose | ||
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | chronic disease review | completed | |
care_element | ldl_cholesterol | ||
care_element | hba1c | ||
appointment | chronic disease review | completed | |
care_element | diastolic_bp | ||
care_element | systolic_bp | ||
appointment | periodic health review | completed |
18 mcg daily
10.4 mmol/L
2026-02-01Smoking Status
current smoker
2025-12-14Diastolic Bp
78 mmHg
2025-08-28Systolic Bp
122 mmHg
2025-08-28Egfr
59 mL/min/1.73m2
2025-05-19Hba1c
8.1 %
2025-05-09Bmi
22.7 kg/m2
2025-04-06Ldl Cholesterol
1.3 mmol/L
2025-01-03Hba1c
8.6 %
2024-10-24Diastolic Bp
80 mmHg
2024-09-24Systolic Bp
115 mmHg
2024-09-24Ldl Cholesterol
2.1 mmol/L
2024-07-09Immunization
Influenza vaccine documented
2024-02-13Diastolic Bp
69 mmHg
2023-12-07Systolic Bp
135 mmHg
2023-12-07Immunization
COVID-19 vaccine documented
2023-08-17Immunization
Pneumococcal vaccine documented
2023-08-13Fasting Glucose
7 mmol/L
2023-08-06Ldl Cholesterol
4.1 mmol/L
2023-04-07Hba1c
8.1 %
2023-03-01Hba1c
9.2 %
2022-10-21Fasting Glucose
8.5 mmol/L
2022-09-09Diastolic Bp
75 mmHg
2022-05-12Systolic Bp
137 mmHg
2022-05-12Ldl Cholesterol
2.4 mmol/L
2022-01-19Hba1c
8.2 %
2021-07-24Diastolic Bp
71 mmHg
2021-02-20Systolic Bp
138 mmHg
2021-02-20