DocChart

Population Health

PHM worklist

Loading action queue

Loading matching patients, saved rows, and evidence layers.

Building the scoped worklist view

PHM worklist

No chronic follow-up

Chronic disease | 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

77 unique / 403

docchart_synthetic_population_300.json

71 here / 300

docchart_synthetic_population_300.json

71 here / 300

synthetic-100-longitudinal.xml

5 here / 100

sample-omd.xml

None here / 0

What This List Is

Chronic disease signal with no completed visit in 6 months.

medium

Structured fact

Needs review

25, active workflow rows

Queued for:

No chronic follow-up

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.

Transitions Between Hospital and HomeQuality Standard linked through AI-CDS guidance retrieval

Patients

Showing 25 of 25 visible rows from 25 matched patients.

25, shown

Bradley Harris

90y | M | English

Priority ,80

needs review

3, flag,s

Care team: Juliana Davies
Last touch: 2025-09-21

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 129/63 mmHg on 2025-11-02

BP 129/63 mmHg on 2025-11-02 · Smoking never smoker on 2026-04-15

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-09-21

Chart

More actions

Carl Lloyd

90y | M | Portuguese

Priority ,80

needs review

3, flag,s

Care team: Eric Lavoie
Last touch: 2025-09-24

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 142/79 mmHg on 2026-05-07

BP 142/79 mmHg on 2026-05-07 · HbA1c 7.2% on 2025-10-05 · eGFR 19.0 mL/min/1.73m2 on 2026-04-19 · ACR 47.3 mg/mmol on 2026-05-27 · Smoking never smoker on 2025-05-29

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-09-24

Chart

More actions

Catherine Glenn

79y | F | French

Priority ,80

needs review

2, flag,s

Care team: Juliana Davies
Last touch: 2024-08-05

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 108/77 mmHg on 2025-03-23

BP 108/77 mmHg on 2025-03-23 · HbA1c 9.0% on 2026-02-08 · eGFR 77.0 mL/min/1.73m2 on 2026-05-04 · ACR 35.5 mg/mmol on 2026-03-10 · Smoking never smoker on 2026-05-23

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2024-08-05

Chart

More actions

Catherine Gomez

88y | F | English

Priority ,80

needs review

1, flag,

Care team: Wole Oduntan
Last touch: 2023-07-18

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

1 open clinical flag

Eye exam evidence missing or overdue | medium | new | active_cohort_automation

Chart care elements

BP 136/78 mmHg on 2026-05-05

BP 136/78 mmHg on 2026-05-05 · HbA1c 7.6% on 2026-02-28 · eGFR 98.0 mL/min/1.73m2 on 2025-10-13 · ACR 42.3 mg/mmol on 2025-11-02 · Smoking never smoker on 2025-12-09

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2023-07-18

Chart

More actions

Dustin Sullivan

79y | M | English

Priority ,80

needs review

1, flag,

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

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 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

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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

Edward Foley

93y | M | French

Priority ,80

needs review

1, flag,

Care team: Amina Farah
Last touch: 2025-03-16

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

1 open clinical flag

Elevated mental health symptom score | high | accepted | clinical_note

Chart care elements

BP 128/69 mmHg on 2026-01-02

BP 128/69 mmHg on 2026-01-02 · eGFR 57.0 mL/min/1.73m2 on 2026-03-06 · ACR 81.4 mg/mmol on 2025-04-01 · Smoking not documented on 2024-10-06

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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

Emily Ruiz

81y | F | English

Priority ,80

needs review

2, flag,s

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

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 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

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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

George Weeks

92y | M | English

Priority ,80

needs review

3, flag,s

Care team: Amina Farah
Last touch: 2024-05-26

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 151/93 mmHg on 2026-02-19

BP 151/93 mmHg on 2026-02-19 · HbA1c 6.0% on 2025-08-02 · eGFR 39.0 mL/min/1.73m2 on 2026-02-08 · ACR 92.7 mg/mmol on 2026-05-11 · Smoking never smoker on 2025-03-14

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2024-05-26

Chart

More actions

James Patterson

94y | M | Tamil

Priority ,80

needs review

1, flag,

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

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 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

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 ,80

needs review

1, flag,

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

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 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

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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

Jim Ray

77y | M | English

Priority ,80

needs review

2, flag,s

Care team: Melinda Chu
Last touch: 2025-02-02

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 141/81 mmHg on 2026-02-03

BP 141/81 mmHg on 2026-02-03 · HbA1c 8.8% on 2026-05-04 · eGFR 65.0 mL/min/1.73m2 on 2026-02-27 · ACR 55.9 mg/mmol on 2025-06-10 · Smoking former smoker on 2026-02-06

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-02-02

Chart

More actions

Kathleen Giles

77y | F | Arabic

Priority ,80

needs review

2, flag,s

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

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 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

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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

Kevin Hendrix

84y | M | English

Priority ,80

needs review

2, flag,s

Care team: Juliana Davies
Last touch: 2025-06-11

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 122/80 mmHg on 2024-05-25

BP 122/80 mmHg on 2024-05-25 · eGFR 46.0 mL/min/1.73m2 on 2025-07-13 · ACR 23.6 mg/mmol on 2026-03-16 · Smoking never smoker on 2026-05-28

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-06-11

Chart

More actions

Manuel Garcia

77y | M | English

Priority ,80

needs review

7, flag,s

Care team: Wole Oduntan
Last touch: 2023-04-18

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

7 open clinical flags

Chart care elements

BP 153/81 mmHg on 2026-02-25

BP 153/81 mmHg on 2026-02-25 · HbA1c 9.9% on 2026-02-11 · eGFR 66.0 mL/min/1.73m2 on 2026-02-02 · ACR 70.1 mg/mmol on 2025-06-06 · Smoking never smoker on 2024-07-27

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2023-04-18

Chart

More actions

Peter Irwin

75y | M | Mandarin

Priority ,80

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2025-11-16

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 146/74 mmHg on 2026-01-01

BP 146/74 mmHg on 2026-01-01 · HbA1c 7.8% on 2026-03-09 · eGFR 50.0 mL/min/1.73m2 on 2026-01-19 · ACR 34.8 mg/mmol on 2025-03-13 · Smoking current smoker on 2025-12-28

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-11-16

Chart

More actions

Priya Patel 007

81y | F | English

Priority ,80

needs review

1, flag,

Care team: Maya Singh
Last touch: 2025-07-22

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

1 open clinical flag

Synthetic diabetes monitoring review | medium | new | synthetic_longitudinal_data

Chart care elements

BP 129/73 mmHg on 2026-06-18

BP 129/73 mmHg on 2026-06-18 · HbA1c 8.3% on 2026-06-18 · eGFR 86 mL/min/1.73m2 on 2026-06-18 · ACR 0.8 mg/mmol on 2026-06-18 · Smoking never on 2026-06-18

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-07-22

Chart

More actions

Rebecca Nolan

75y | F | English

Priority ,80

needs review

1, flag,

Care team: Eric Lavoie
Last touch: 2025-02-01

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

1 open clinical flag

Dementia care plan review | medium | new | clinical_note

Chart care elements

BP 132/78 mmHg on 2026-03-01

BP 132/78 mmHg on 2026-03-01 · HbA1c 5.3% on 2023-12-16 · eGFR 57.0 mL/min/1.73m2 on 2026-04-10 · ACR 62.0 mg/mmol on 2025-10-11 · Smoking former smoker on 2026-03-19

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-02-01

Chart

More actions

Steven Gomez

92y | M | French

Priority ,80

needs review

2, flag,s

Care team: Wole Oduntan
Last touch: 2025-01-19

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 124/69 mmHg on 2024-12-13

BP 124/69 mmHg on 2024-12-13 · HbA1c 5.5% on 2025-09-13 · eGFR 44.0 mL/min/1.73m2 on 2026-05-22 · ACR 39.7 mg/mmol on 2025-09-17 · Smoking former smoker on 2025-10-11

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-01-19

Chart

More actions

Tammy Francis

79y | F | English

Priority ,80

needs review

3, flag,s

Care team: Amina Farah
Last touch: 2025-01-17

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 134/70 mmHg on 2025-06-09

BP 134/70 mmHg on 2025-06-09 · HbA1c 8.3% on 2026-04-22 · eGFR 44.0 mL/min/1.73m2 on 2026-03-24 · ACR 46.3 mg/mmol on 2025-05-17 · Smoking never smoker on 2025-08-05

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-01-17

Chart

More actions

Travis Sims

75y | M | Portuguese

Priority ,80

needs review

2, flag,s

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

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 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

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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

Benjamin Huerta

68y | M | English

Priority ,70

needs review

4, flag,s

Care team: Amina Farah
Last touch: 2023-05-20

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

4 open clinical flags

Chart care elements

BP 112/87 mmHg on 2026-03-24

BP 112/87 mmHg on 2026-03-24 · HbA1c 8.9% on 2026-04-15 · eGFR 59.0 mL/min/1.73m2 on 2025-05-19 · ACR 13.7 mg/mmol on 2026-04-18 · Smoking current smoker on 2025-12-14

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2023-05-20

Chart

More actions

Johnny Johnson

69y | M | English

Priority ,70

needs review

3, flag,s

Care team: Melinda Chu
Last touch: 2022-06-17

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 132/92 mmHg on 2024-12-29

BP 132/92 mmHg on 2024-12-29 · HbA1c 6.3% on 2025-08-04 · Smoking former smoker on 2026-03-21

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2022-06-17

Chart

More actions

Mark Finley

52y | M | French

Priority ,70

needs review

3, flag,s

Care team: Amina Farah
Last touch: 2024-03-26

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 165/93 mmHg on 2026-03-07

BP 165/93 mmHg on 2026-03-07 · HbA1c 8.6% on 2026-02-25 · eGFR 79.0 mL/min/1.73m2 on 2025-10-23 · ACR 12.1 mg/mmol on 2026-04-16 · Smoking never smoker on 2025-08-01

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2024-03-26

Chart

More actions

Michael Taylor

64y | M | Farsi

Priority ,70

needs review

4, flag,s

Care team: Juliana Davies
Last touch: 2025-07-28

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

4 open clinical flags

Chart care elements

BP 146/87 mmHg on 2026-05-28

BP 146/87 mmHg on 2026-05-28 · HbA1c 8.4% on 2026-03-18 · eGFR 46.0 mL/min/1.73m2 on 2024-12-17 · ACR 58.2 mg/mmol on 2025-10-14 · Smoking never smoker on 2025-10-15

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-07-28

Chart

More actions

Robert Perez

51y | M | French

Priority ,70

needs review

6, flag,s

Care team: Eric Lavoie
Last touch: 2025-05-13

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

6 open clinical flags

Chart care elements

BP 137/73 mmHg on 2025-10-19

BP 137/73 mmHg on 2025-10-19 · HbA1c 5.5% on 2024-04-25 · Smoking former smoker on 2026-04-10

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-05-13

Chart

More actions

25, shown

Bradley Harris

90y | M | English

Priority ,80

needs review

3, flag,s

Care team: Juliana Davies
Last touch: 2025-09-21

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 129/63 mmHg on 2025-11-02

BP 129/63 mmHg on 2025-11-02 · Smoking never smoker on 2026-04-15

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-09-21

Chart

More actions

Carl Lloyd

90y | M | Portuguese

Priority ,80

needs review

3, flag,s

Care team: Eric Lavoie
Last touch: 2025-09-24

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 142/79 mmHg on 2026-05-07

BP 142/79 mmHg on 2026-05-07 · HbA1c 7.2% on 2025-10-05 · eGFR 19.0 mL/min/1.73m2 on 2026-04-19 · ACR 47.3 mg/mmol on 2026-05-27 · Smoking never smoker on 2025-05-29

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-09-24

Chart

More actions

Catherine Glenn

79y | F | French

Priority ,80

needs review

2, flag,s

Care team: Juliana Davies
Last touch: 2024-08-05

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 108/77 mmHg on 2025-03-23

BP 108/77 mmHg on 2025-03-23 · HbA1c 9.0% on 2026-02-08 · eGFR 77.0 mL/min/1.73m2 on 2026-05-04 · ACR 35.5 mg/mmol on 2026-03-10 · Smoking never smoker on 2026-05-23

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2024-08-05

Chart

More actions

Catherine Gomez

88y | F | English

Priority ,80

needs review

1, flag,

Care team: Wole Oduntan
Last touch: 2023-07-18

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

1 open clinical flag

Eye exam evidence missing or overdue | medium | new | active_cohort_automation

Chart care elements

BP 136/78 mmHg on 2026-05-05

BP 136/78 mmHg on 2026-05-05 · HbA1c 7.6% on 2026-02-28 · eGFR 98.0 mL/min/1.73m2 on 2025-10-13 · ACR 42.3 mg/mmol on 2025-11-02 · Smoking never smoker on 2025-12-09

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2023-07-18

Chart

More actions

Dustin Sullivan

79y | M | English

Priority ,80

needs review

1, flag,

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

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 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

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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

Edward Foley

93y | M | French

Priority ,80

needs review

1, flag,

Care team: Amina Farah
Last touch: 2025-03-16

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

1 open clinical flag

Elevated mental health symptom score | high | accepted | clinical_note

Chart care elements

BP 128/69 mmHg on 2026-01-02

BP 128/69 mmHg on 2026-01-02 · eGFR 57.0 mL/min/1.73m2 on 2026-03-06 · ACR 81.4 mg/mmol on 2025-04-01 · Smoking not documented on 2024-10-06

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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

Emily Ruiz

81y | F | English

Priority ,80

needs review

2, flag,s

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

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 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

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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

George Weeks

92y | M | English

Priority ,80

needs review

3, flag,s

Care team: Amina Farah
Last touch: 2024-05-26

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 151/93 mmHg on 2026-02-19

BP 151/93 mmHg on 2026-02-19 · HbA1c 6.0% on 2025-08-02 · eGFR 39.0 mL/min/1.73m2 on 2026-02-08 · ACR 92.7 mg/mmol on 2026-05-11 · Smoking never smoker on 2025-03-14

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2024-05-26

Chart

More actions

James Patterson

94y | M | Tamil

Priority ,80

needs review

1, flag,

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

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 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

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 ,80

needs review

1, flag,

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

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 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

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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

Jim Ray

77y | M | English

Priority ,80

needs review

2, flag,s

Care team: Melinda Chu
Last touch: 2025-02-02

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 141/81 mmHg on 2026-02-03

BP 141/81 mmHg on 2026-02-03 · HbA1c 8.8% on 2026-05-04 · eGFR 65.0 mL/min/1.73m2 on 2026-02-27 · ACR 55.9 mg/mmol on 2025-06-10 · Smoking former smoker on 2026-02-06

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-02-02

Chart

More actions

Kathleen Giles

77y | F | Arabic

Priority ,80

needs review

2, flag,s

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

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 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

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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

Kevin Hendrix

84y | M | English

Priority ,80

needs review

2, flag,s

Care team: Juliana Davies
Last touch: 2025-06-11

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 122/80 mmHg on 2024-05-25

BP 122/80 mmHg on 2024-05-25 · eGFR 46.0 mL/min/1.73m2 on 2025-07-13 · ACR 23.6 mg/mmol on 2026-03-16 · Smoking never smoker on 2026-05-28

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-06-11

Chart

More actions

Manuel Garcia

77y | M | English

Priority ,80

needs review

7, flag,s

Care team: Wole Oduntan
Last touch: 2023-04-18

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

7 open clinical flags

Chart care elements

BP 153/81 mmHg on 2026-02-25

BP 153/81 mmHg on 2026-02-25 · HbA1c 9.9% on 2026-02-11 · eGFR 66.0 mL/min/1.73m2 on 2026-02-02 · ACR 70.1 mg/mmol on 2025-06-06 · Smoking never smoker on 2024-07-27

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2023-04-18

Chart

More actions

Peter Irwin

75y | M | Mandarin

Priority ,80

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2025-11-16

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 146/74 mmHg on 2026-01-01

BP 146/74 mmHg on 2026-01-01 · HbA1c 7.8% on 2026-03-09 · eGFR 50.0 mL/min/1.73m2 on 2026-01-19 · ACR 34.8 mg/mmol on 2025-03-13 · Smoking current smoker on 2025-12-28

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-11-16

Chart

More actions

Priya Patel 007

81y | F | English

Priority ,80

needs review

1, flag,

Care team: Maya Singh
Last touch: 2025-07-22

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

1 open clinical flag

Synthetic diabetes monitoring review | medium | new | synthetic_longitudinal_data

Chart care elements

BP 129/73 mmHg on 2026-06-18

BP 129/73 mmHg on 2026-06-18 · HbA1c 8.3% on 2026-06-18 · eGFR 86 mL/min/1.73m2 on 2026-06-18 · ACR 0.8 mg/mmol on 2026-06-18 · Smoking never on 2026-06-18

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-07-22

Chart

More actions

Rebecca Nolan

75y | F | English

Priority ,80

needs review

1, flag,

Care team: Eric Lavoie
Last touch: 2025-02-01

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

1 open clinical flag

Dementia care plan review | medium | new | clinical_note

Chart care elements

BP 132/78 mmHg on 2026-03-01

BP 132/78 mmHg on 2026-03-01 · HbA1c 5.3% on 2023-12-16 · eGFR 57.0 mL/min/1.73m2 on 2026-04-10 · ACR 62.0 mg/mmol on 2025-10-11 · Smoking former smoker on 2026-03-19

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-02-01

Chart

More actions

Steven Gomez

92y | M | French

Priority ,80

needs review

2, flag,s

Care team: Wole Oduntan
Last touch: 2025-01-19

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

2 open clinical flags

Chart care elements

BP 124/69 mmHg on 2024-12-13

BP 124/69 mmHg on 2024-12-13 · HbA1c 5.5% on 2025-09-13 · eGFR 44.0 mL/min/1.73m2 on 2026-05-22 · ACR 39.7 mg/mmol on 2025-09-17 · Smoking former smoker on 2025-10-11

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-01-19

Chart

More actions

Tammy Francis

79y | F | English

Priority ,80

needs review

3, flag,s

Care team: Amina Farah
Last touch: 2025-01-17

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 134/70 mmHg on 2025-06-09

BP 134/70 mmHg on 2025-06-09 · HbA1c 8.3% on 2026-04-22 · eGFR 44.0 mL/min/1.73m2 on 2026-03-24 · ACR 46.3 mg/mmol on 2025-05-17 · Smoking never smoker on 2025-08-05

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-01-17

Chart

More actions

Travis Sims

75y | M | Portuguese

Priority ,80

needs review

2, flag,s

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

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 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

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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

Benjamin Huerta

68y | M | English

Priority ,70

needs review

4, flag,s

Care team: Amina Farah
Last touch: 2023-05-20

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

4 open clinical flags

Chart care elements

BP 112/87 mmHg on 2026-03-24

BP 112/87 mmHg on 2026-03-24 · HbA1c 8.9% on 2026-04-15 · eGFR 59.0 mL/min/1.73m2 on 2025-05-19 · ACR 13.7 mg/mmol on 2026-04-18 · Smoking current smoker on 2025-12-14

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2023-05-20

Chart

More actions

Johnny Johnson

69y | M | English

Priority ,70

needs review

3, flag,s

Care team: Melinda Chu
Last touch: 2022-06-17

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 132/92 mmHg on 2024-12-29

BP 132/92 mmHg on 2024-12-29 · HbA1c 6.3% on 2025-08-04 · Smoking former smoker on 2026-03-21

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2022-06-17

Chart

More actions

Mark Finley

52y | M | French

Priority ,70

needs review

3, flag,s

Care team: Amina Farah
Last touch: 2024-03-26

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

3 open clinical flags

Chart care elements

BP 165/93 mmHg on 2026-03-07

BP 165/93 mmHg on 2026-03-07 · HbA1c 8.6% on 2026-02-25 · eGFR 79.0 mL/min/1.73m2 on 2025-10-23 · ACR 12.1 mg/mmol on 2026-04-16 · Smoking never smoker on 2025-08-01

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2024-03-26

Chart

More actions

Michael Taylor

64y | M | Farsi

Priority ,70

needs review

4, flag,s

Care team: Juliana Davies
Last touch: 2025-07-28

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

4 open clinical flags

Chart care elements

BP 146/87 mmHg on 2026-05-28

BP 146/87 mmHg on 2026-05-28 · HbA1c 8.4% on 2026-03-18 · eGFR 46.0 mL/min/1.73m2 on 2024-12-17 · ACR 58.2 mg/mmol on 2025-10-14 · Smoking never smoker on 2025-10-15

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-07-28

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Robert Perez

51y | M | French

Priority ,70

needs review

6, flag,s

Care team: Eric Lavoie
Last touch: 2025-05-13

5 evidence layers

Structured fact

DocChart PHM rule

No chronic follow-up 2026.05

Chronic disease signal with no completed visit in 6 months.

DocChart flags

6 open clinical flags

Chart care elements

BP 137/73 mmHg on 2025-10-19

BP 137/73 mmHg on 2025-10-19 · HbA1c 5.5% on 2024-04-25 · Smoking former smoker on 2026-04-10

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Transitions Between Hospital and Home

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 2025-05-13

Chart

More actions