DocChart

Population Health

PHM worklist

Loading action queue

Loading matching patients, saved rows, and evidence layers.

Building the scoped worklist view

PHM worklist

Kidney monitoring overdue

Diabetes / HTN / CKD | showing the first 25 patients for fast loading.
Queue mode: Last saved list.

PHM

Cohort

Ask

Patient scope

All clinic patients

Counts are unique patients. Import scopes can overlap when several uploaded files contain the same patient.

All patients

55 unique / 403

docchart_synthetic_population_300.json

54 here / 300

docchart_synthetic_population_300.json

54 here / 300

synthetic-100-longitudinal.xml

None here / 100

sample-omd.xml

None here / 0

What This List Is

Kidney monitoring evidence missing in the last 12 months.

high

Structured fact

Needs review

25, active workflow rows

Queued for:

Kidney monitoring overdue

How selected:

Deterministic rule + clinician review

Where saved:

PHM workflow rows; escalations become Flags & Tasks.

When updated:

Create queue adds new matches; existing decisions stay saved.

Priority & AI-CDS Evidence

Priority score from the configured PHM rule: base priority plus modifiers such as open flags, age, linked care gaps, or follow-up gaps. Scores are capped at 100.

It is a sorting signal, not a diagnosis. The score combines the rule base priority with modifiers such as open flags, age, overdue visits, or linked care gaps.

Quality Standards:

CEP resources:

Workflow

Save a work queue, then use each patient card to record what happened next.

Build cohort

Ask AI

1. Match

DocChart finds patients who match this rule.

2. Queue

patients are waiting for action.

3. Act

Record call, recall, flag, book, snooze, or close.

4. AI-CDS

Use AI/CDS or cohorts when you need more context.

Current view: Patients from the most recent saved queue run.

Most staff work from Active saved rows after saving today's list.

Prediabetes and Type 2 DiabetesQuality Standard linked through AI-CDS guidance retrieval Medication SafetyQuality Standard linked through AI-CDS guidance retrieval

Patients

Showing 25 of 25 visible rows from 25 matched patients.

25, shown

Amber Humphrey

84y | F | French

Priority ,95

needs review

4, flag,s

Care team: Eric Lavoie
Last touch: 2026-02-11

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

4 open clinical flags

Chart care elements

BP 140/77 mmHg on 2026-02-23

BP 140/77 mmHg on 2026-02-23 · HbA1c 6.0% on 2026-03-06 · eGFR 63.0 mL/min/1.73m2 on 2025-02-25 · Smoking never smoker on 2026-02-02

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-02-11

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More actions

Andrew Kelly

68y | M | English

Priority ,95

needs review

4, flag,s

Care team: Eric Lavoie
Last touch: 2026-03-01

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

4 open clinical flags

Chart care elements

BP 149/84 mmHg on 2026-03-15

BP 149/84 mmHg on 2026-03-15 · HbA1c 5.1% on 2024-02-18 · eGFR 18 mL/min/1.73m2 on 2025-05-21 · ACR 85.7 mg/mmol on 2025-05-16 · Smoking never smoker on 2025-08-15

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-03-01

Chart

More actions

Cody Hernandez

74y | M | English

Priority ,95

needs review

2, flag,s

Care team: Juliana Davies
Last touch: 2025-02-14

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 133/81 mmHg on 2025-05-10

BP 133/81 mmHg on 2025-05-10 · HbA1c 5.5% on 2025-11-09 · Smoking former smoker on 2026-02-17

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-02-14

Chart

More actions

Diane Hunt

66y | F | English

Priority ,95

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2026-02-17

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 149/90 mmHg on 2025-06-16

BP 149/90 mmHg on 2025-06-16 · Smoking former smoker on 2025-01-16

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-02-17

Chart

More actions

Dustin Sullivan

79y | M | English

Priority ,95

needs review

1, flag,

Care team: Melinda Chu
Last touch: 2024-12-06

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

1 open clinical flag

Prediabetes range HbA1c | medium | accepted | structured_fact

Chart care elements

BP 143/80 mmHg on 2026-04-25

BP 143/80 mmHg on 2026-04-25 · HbA1c 5.9% on 2026-02-01 · eGFR 48.0 mL/min/1.73m2 on 2024-11-03 · ACR 64.6 mg/mmol on 2025-04-06 · Smoking never smoker on 2025-12-04

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2024-12-06

Chart

More actions

Emily Ruiz

81y | F | English

Priority ,95

needs review

2, flag,s

Care team: Wole Oduntan
Last touch: 2025-03-16

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 127/69 mmHg on 2026-05-22

BP 127/69 mmHg on 2026-05-22 · Smoking never smoker on 2024-12-07

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-03-16

Chart

More actions

Hunter Roy

78y | M | English

Priority ,95

needs review

1, flag,

Care team: Amina Farah
Last touch: 2026-03-07

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

1 open clinical flag

Pneumococcal immunization review | medium | accepted | active_cohort_automation

Chart care elements

BP 144/64 mmHg on 2026-01-12

BP 144/64 mmHg on 2026-01-12 · HbA1c 5.0% on 2026-02-24 · eGFR 93.0 mL/min/1.73m2 on 2023-12-29 · Smoking never smoker on 2025-06-17

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-03-07

Chart

More actions

James Patterson

94y | M | Tamil

Priority ,95

needs review

1, flag,

Care team: Amina Farah
Last touch: 2025-03-11

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

1 open clinical flag

Repeated BP above target | high | new | structured_fact

Chart care elements

BP 153/81 mmHg on 2026-01-02

BP 153/81 mmHg on 2026-01-02 · eGFR 88.0 mL/min/1.73m2 on 2024-02-01 · Smoking never smoker on 2026-02-15

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-03-11

Chart

More actions

Jeffrey Wagner

94y | M | Portuguese

Priority ,95

needs review

1, flag,

Care team: Amina Farah
Last touch: 2024-01-06

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

1 open clinical flag

Falls risk review due | medium | new | clinical_note

Chart care elements

BP 125/66 mmHg on 2026-04-11

BP 125/66 mmHg on 2026-04-11 · Smoking not documented on 2025-03-07

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2024-01-06

Chart

More actions

Kathleen Giles

77y | F | Arabic

Priority ,95

needs review

2, flag,s

Care team: Juliana Davies
Last touch: 2023-11-26

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Influenza immunization recall | low | new | structured_fact · Opioid monitoring review due | high | new | structured_fact

Chart care elements

BP 113/68 mmHg on 2026-04-08

BP 113/68 mmHg on 2026-04-08 · HbA1c 5.0% on 2024-02-14 · Smoking never smoker on 2026-04-04

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2023-11-26

Chart

More actions

Laura Case

67y | F | English

Priority ,95

needs review

2, flag,s

Care team: Melinda Chu
Last touch: 2026-05-26

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 158/91 mmHg on 2025-05-23

BP 158/91 mmHg on 2025-05-23 · eGFR 93.0 mL/min/1.73m2 on 2024-05-05 · Smoking former smoker on 2026-01-30

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-05-26

Chart

More actions

Mark Combs

65y | M | Spanish

Priority ,95

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2026-03-09

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 145/76 mmHg on 2025-03-16

BP 145/76 mmHg on 2025-03-16 · HbA1c 6.1% on 2023-09-19 · eGFR 81.0 mL/min/1.73m2 on 2024-04-14 · Smoking never smoker on 2025-03-05

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-03-09

Chart

More actions

Mary Rose

85y | F | English

Priority ,95

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2026-04-22

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 155/84 mmHg on 2025-01-22

BP 155/84 mmHg on 2025-01-22 · HbA1c 5.3% on 2026-03-18 · Smoking never smoker on 2025-02-05

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-04-22

Chart

More actions

Monica Schroeder

71y | F | English

Priority ,95

needs review

1, flag,

Care team: Wole Oduntan
Last touch: 2025-07-01

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

1 open clinical flag

Pneumococcal immunization review | medium | new | active_cohort_automation

Chart care elements

BP 129/80 mmHg on 2026-05-07

BP 129/80 mmHg on 2026-05-07 · Smoking never smoker on 2025-04-22

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-07-01

Chart

More actions

Phillip Smith

66y | M | English

Priority ,95

needs review

1, flag,

Care team: Amina Farah
Last touch: 2025-07-24

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

1 open clinical flag

Age-eligible screening missing | medium | new | clinical_note

Chart care elements

BP 140/66 mmHg on 2026-04-12

BP 140/66 mmHg on 2026-04-12 · eGFR 67.0 mL/min/1.73m2 on 2024-02-11 · Smoking current smoker on 2024-10-13

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-07-24

Chart

More actions

Richard Richards

67y | M | French

Priority ,95

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2025-04-21

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 144/80 mmHg on 2026-02-08

BP 144/80 mmHg on 2026-02-08 · HbA1c 6.3% on 2025-01-24 · Smoking never smoker on 2024-10-18

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-04-21

Chart

More actions

Scott Hawkins

72y | M | English

Priority ,95

needs review

3, flag,s

Care team: Eric Lavoie
Last touch: 2026-03-02

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 128/68 mmHg on 2023-03-01

BP 128/68 mmHg on 2023-03-01 · Smoking former smoker on 2026-03-05

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-03-02

Chart

More actions

Tracy Brown

73y | F | English

Priority ,95

needs review

2, flag,s

Care team: Melinda Chu
Last touch: 2026-04-12

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 126/80 mmHg on 2026-01-18

BP 126/80 mmHg on 2026-01-18 · Smoking never smoker on 2024-07-30

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-04-12

Chart

More actions

Travis Sims

75y | M | Portuguese

Priority ,95

needs review

2, flag,s

Care team: Juliana Davies
Last touch: 2023-09-07

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 115/73 mmHg on 2026-05-06

BP 115/73 mmHg on 2026-05-06 · Smoking never smoker on 2026-05-27

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2023-09-07

Chart

More actions

Troy Bailey

88y | M | English

Priority ,95

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2026-04-12

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 150/81 mmHg on 2026-01-17

BP 150/81 mmHg on 2026-01-17 · HbA1c 8.7% on 2026-02-07 · eGFR 83.0 mL/min/1.73m2 on 2025-05-19 · Smoking never smoker on 2025-04-04

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-04-12

Chart

More actions

Cheyenne Mclaughlin

64y | F | Urdu

Priority ,87

needs review

4, flag,s

Care team: Juliana Davies
Last touch: 2026-05-10

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

4 open clinical flags

Chart care elements

BP 144/75 mmHg on 2026-02-11

BP 144/75 mmHg on 2026-02-11 · Smoking former smoker on 2024-06-29

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-05-10

Chart

More actions

Christopher Solis

54y | M | Portuguese

Priority ,87

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2026-02-28

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 123/89 mmHg on 2026-04-04

BP 123/89 mmHg on 2026-04-04 · HbA1c 6.3% on 2026-02-15 · eGFR 94.0 mL/min/1.73m2 on 2024-05-30 · Smoking current smoker on 2024-10-30

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-02-28

Chart

More actions

Jeffrey White

47y | M | Spanish

Priority ,87

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2025-07-01

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 135/78 mmHg on 2026-03-07

BP 135/78 mmHg on 2026-03-07 · HbA1c 5.9% on 2025-07-24 · Smoking never smoker on 2025-07-29

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-07-01

Chart

More actions

Joy Myers

51y | F | English

Priority ,87

needs review

5, flag,s

Care team: Eric Lavoie
Last touch: 2026-03-28

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

5 open clinical flags

Chart care elements

BP 131/87 mmHg on 2026-04-16

BP 131/87 mmHg on 2026-04-16 · HbA1c 8.0% on 2026-03-15 · Smoking never smoker on 2025-01-23

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-03-28

Chart

More actions

Walter Williams

62y | M | English

Priority ,87

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2026-03-29

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 148/85 mmHg on 2026-05-20

BP 148/85 mmHg on 2026-05-20 · HbA1c 7.2% on 2026-04-22 · ACR 9.9 mg/mmol on 2025-01-25 · Smoking never smoker on 2026-01-15

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-03-29

Chart

More actions

25, shown

Amber Humphrey

84y | F | French

Priority ,95

needs review

4, flag,s

Care team: Eric Lavoie
Last touch: 2026-02-11

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

4 open clinical flags

Chart care elements

BP 140/77 mmHg on 2026-02-23

BP 140/77 mmHg on 2026-02-23 · HbA1c 6.0% on 2026-03-06 · eGFR 63.0 mL/min/1.73m2 on 2025-02-25 · Smoking never smoker on 2026-02-02

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-02-11

Chart

More actions

Andrew Kelly

68y | M | English

Priority ,95

needs review

4, flag,s

Care team: Eric Lavoie
Last touch: 2026-03-01

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

4 open clinical flags

Chart care elements

BP 149/84 mmHg on 2026-03-15

BP 149/84 mmHg on 2026-03-15 · HbA1c 5.1% on 2024-02-18 · eGFR 18 mL/min/1.73m2 on 2025-05-21 · ACR 85.7 mg/mmol on 2025-05-16 · Smoking never smoker on 2025-08-15

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-03-01

Chart

More actions

Cody Hernandez

74y | M | English

Priority ,95

needs review

2, flag,s

Care team: Juliana Davies
Last touch: 2025-02-14

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 133/81 mmHg on 2025-05-10

BP 133/81 mmHg on 2025-05-10 · HbA1c 5.5% on 2025-11-09 · Smoking former smoker on 2026-02-17

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-02-14

Chart

More actions

Diane Hunt

66y | F | English

Priority ,95

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2026-02-17

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 149/90 mmHg on 2025-06-16

BP 149/90 mmHg on 2025-06-16 · Smoking former smoker on 2025-01-16

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-02-17

Chart

More actions

Dustin Sullivan

79y | M | English

Priority ,95

needs review

1, flag,

Care team: Melinda Chu
Last touch: 2024-12-06

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

1 open clinical flag

Prediabetes range HbA1c | medium | accepted | structured_fact

Chart care elements

BP 143/80 mmHg on 2026-04-25

BP 143/80 mmHg on 2026-04-25 · HbA1c 5.9% on 2026-02-01 · eGFR 48.0 mL/min/1.73m2 on 2024-11-03 · ACR 64.6 mg/mmol on 2025-04-06 · Smoking never smoker on 2025-12-04

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2024-12-06

Chart

More actions

Emily Ruiz

81y | F | English

Priority ,95

needs review

2, flag,s

Care team: Wole Oduntan
Last touch: 2025-03-16

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 127/69 mmHg on 2026-05-22

BP 127/69 mmHg on 2026-05-22 · Smoking never smoker on 2024-12-07

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-03-16

Chart

More actions

Hunter Roy

78y | M | English

Priority ,95

needs review

1, flag,

Care team: Amina Farah
Last touch: 2026-03-07

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

1 open clinical flag

Pneumococcal immunization review | medium | accepted | active_cohort_automation

Chart care elements

BP 144/64 mmHg on 2026-01-12

BP 144/64 mmHg on 2026-01-12 · HbA1c 5.0% on 2026-02-24 · eGFR 93.0 mL/min/1.73m2 on 2023-12-29 · Smoking never smoker on 2025-06-17

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-03-07

Chart

More actions

James Patterson

94y | M | Tamil

Priority ,95

needs review

1, flag,

Care team: Amina Farah
Last touch: 2025-03-11

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

1 open clinical flag

Repeated BP above target | high | new | structured_fact

Chart care elements

BP 153/81 mmHg on 2026-01-02

BP 153/81 mmHg on 2026-01-02 · eGFR 88.0 mL/min/1.73m2 on 2024-02-01 · Smoking never smoker on 2026-02-15

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-03-11

Chart

More actions

Jeffrey Wagner

94y | M | Portuguese

Priority ,95

needs review

1, flag,

Care team: Amina Farah
Last touch: 2024-01-06

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

1 open clinical flag

Falls risk review due | medium | new | clinical_note

Chart care elements

BP 125/66 mmHg on 2026-04-11

BP 125/66 mmHg on 2026-04-11 · Smoking not documented on 2025-03-07

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2024-01-06

Chart

More actions

Kathleen Giles

77y | F | Arabic

Priority ,95

needs review

2, flag,s

Care team: Juliana Davies
Last touch: 2023-11-26

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Influenza immunization recall | low | new | structured_fact · Opioid monitoring review due | high | new | structured_fact

Chart care elements

BP 113/68 mmHg on 2026-04-08

BP 113/68 mmHg on 2026-04-08 · HbA1c 5.0% on 2024-02-14 · Smoking never smoker on 2026-04-04

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2023-11-26

Chart

More actions

Laura Case

67y | F | English

Priority ,95

needs review

2, flag,s

Care team: Melinda Chu
Last touch: 2026-05-26

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 158/91 mmHg on 2025-05-23

BP 158/91 mmHg on 2025-05-23 · eGFR 93.0 mL/min/1.73m2 on 2024-05-05 · Smoking former smoker on 2026-01-30

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-05-26

Chart

More actions

Mark Combs

65y | M | Spanish

Priority ,95

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2026-03-09

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 145/76 mmHg on 2025-03-16

BP 145/76 mmHg on 2025-03-16 · HbA1c 6.1% on 2023-09-19 · eGFR 81.0 mL/min/1.73m2 on 2024-04-14 · Smoking never smoker on 2025-03-05

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-03-09

Chart

More actions

Mary Rose

85y | F | English

Priority ,95

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2026-04-22

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 155/84 mmHg on 2025-01-22

BP 155/84 mmHg on 2025-01-22 · HbA1c 5.3% on 2026-03-18 · Smoking never smoker on 2025-02-05

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-04-22

Chart

More actions

Monica Schroeder

71y | F | English

Priority ,95

needs review

1, flag,

Care team: Wole Oduntan
Last touch: 2025-07-01

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

1 open clinical flag

Pneumococcal immunization review | medium | new | active_cohort_automation

Chart care elements

BP 129/80 mmHg on 2026-05-07

BP 129/80 mmHg on 2026-05-07 · Smoking never smoker on 2025-04-22

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-07-01

Chart

More actions

Phillip Smith

66y | M | English

Priority ,95

needs review

1, flag,

Care team: Amina Farah
Last touch: 2025-07-24

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

1 open clinical flag

Age-eligible screening missing | medium | new | clinical_note

Chart care elements

BP 140/66 mmHg on 2026-04-12

BP 140/66 mmHg on 2026-04-12 · eGFR 67.0 mL/min/1.73m2 on 2024-02-11 · Smoking current smoker on 2024-10-13

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-07-24

Chart

More actions

Richard Richards

67y | M | French

Priority ,95

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2025-04-21

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 144/80 mmHg on 2026-02-08

BP 144/80 mmHg on 2026-02-08 · HbA1c 6.3% on 2025-01-24 · Smoking never smoker on 2024-10-18

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-04-21

Chart

More actions

Scott Hawkins

72y | M | English

Priority ,95

needs review

3, flag,s

Care team: Eric Lavoie
Last touch: 2026-03-02

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 128/68 mmHg on 2023-03-01

BP 128/68 mmHg on 2023-03-01 · Smoking former smoker on 2026-03-05

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-03-02

Chart

More actions

Tracy Brown

73y | F | English

Priority ,95

needs review

2, flag,s

Care team: Melinda Chu
Last touch: 2026-04-12

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 126/80 mmHg on 2026-01-18

BP 126/80 mmHg on 2026-01-18 · Smoking never smoker on 2024-07-30

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-04-12

Chart

More actions

Travis Sims

75y | M | Portuguese

Priority ,95

needs review

2, flag,s

Care team: Juliana Davies
Last touch: 2023-09-07

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 115/73 mmHg on 2026-05-06

BP 115/73 mmHg on 2026-05-06 · Smoking never smoker on 2026-05-27

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2023-09-07

Chart

More actions

Troy Bailey

88y | M | English

Priority ,95

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2026-04-12

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 150/81 mmHg on 2026-01-17

BP 150/81 mmHg on 2026-01-17 · HbA1c 8.7% on 2026-02-07 · eGFR 83.0 mL/min/1.73m2 on 2025-05-19 · Smoking never smoker on 2025-04-04

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-04-12

Chart

More actions

Cheyenne Mclaughlin

64y | F | Urdu

Priority ,87

needs review

4, flag,s

Care team: Juliana Davies
Last touch: 2026-05-10

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

4 open clinical flags

Chart care elements

BP 144/75 mmHg on 2026-02-11

BP 144/75 mmHg on 2026-02-11 · Smoking former smoker on 2024-06-29

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-05-10

Chart

More actions

Christopher Solis

54y | M | Portuguese

Priority ,87

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2026-02-28

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 123/89 mmHg on 2026-04-04

BP 123/89 mmHg on 2026-04-04 · HbA1c 6.3% on 2026-02-15 · eGFR 94.0 mL/min/1.73m2 on 2024-05-30 · Smoking current smoker on 2024-10-30

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-02-28

Chart

More actions

Jeffrey White

47y | M | Spanish

Priority ,87

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2025-07-01

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 135/78 mmHg on 2026-03-07

BP 135/78 mmHg on 2026-03-07 · HbA1c 5.9% on 2025-07-24 · Smoking never smoker on 2025-07-29

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-07-01

Chart

More actions

Joy Myers

51y | F | English

Priority ,87

needs review

5, flag,s

Care team: Eric Lavoie
Last touch: 2026-03-28

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

5 open clinical flags

Chart care elements

BP 131/87 mmHg on 2026-04-16

BP 131/87 mmHg on 2026-04-16 · HbA1c 8.0% on 2026-03-15 · Smoking never smoker on 2025-01-23

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-03-28

Chart

More actions

Walter Williams

62y | M | English

Priority ,87

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2026-03-29

5 evidence layers

Structured fact

DocChart PHM rule

Kidney monitoring overdue 2026.05

Kidney monitoring evidence missing in the last 12 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 148/85 mmHg on 2026-05-20

BP 148/85 mmHg on 2026-05-20 · HbA1c 7.2% on 2026-04-22 · ACR 9.9 mg/mmol on 2025-01-25 · Smoking never smoker on 2026-01-15

Evidence details (3)

AI-CDS guidance

2 Quality Standards / 0 CEP resources

Prediabetes and Type 2 Diabetes · Medication Safety

Workflow state

needs review

Not yet acted on in the saved PHM workflow.

Matched by:

structured record

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-03-29

Chart

More actions