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

Import: synthetic-100-longitudinal.xml | Chronic disease | showing the first 5 patients for fast loading.
Queue mode: Last saved list.

PHM

Cohort

Ask

Patient scope

Import: synthetic-100-longitudinal.xml

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

5, 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 5 of 5 visible rows from 5 matched patients.

5, shown

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

Daniel Brown 064

54y | M | French

Priority ,70

needs review

1, flag,

Care team: Maya Singh
Last touch: 2025-08-02

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

1 open clinical flag

Synthetic BP follow-up review | medium | new | synthetic_longitudinal_data

Chart care elements

BP 142/86 mmHg on 2026-03-03

BP 142/86 mmHg on 2026-03-03 · HbA1c 5.3% on 2026-03-03 · eGFR 81 mL/min/1.73m2 on 2026-03-03 · ACR 1.7 mg/mmol on 2026-03-03 · Smoking never on 2026-03-03

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 2025-08-02

Chart

More actions

Fatima Ali 045

63y | X | English

Priority ,70

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2025-08-06

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

2 open clinical flags

Chart care elements

BP 149/95 mmHg on 2026-08-08

BP 149/95 mmHg on 2026-08-08 · HbA1c 7.3% on 2026-08-08 · eGFR 93 mL/min/1.73m2 on 2026-08-08 · ACR 1.4 mg/mmol on 2026-08-08 · Smoking never on 2026-08-08

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 2025-08-06

Chart

More actions

Lucas Martin 026

72y | M | English

Priority ,70

needs review

1, flag,

Care team: Maya Singh
Last touch: 2025-07-18

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

Synthetic diabetes monitoring review | medium | new | synthetic_longitudinal_data

Chart care elements

BP 124/79 mmHg on 2026-01-13

BP 124/79 mmHg on 2026-01-13 · HbA1c 7.8% on 2026-01-13 · eGFR 74 mL/min/1.73m2 on 2026-01-13 · ACR 1.1 mg/mmol on 2026-01-13 · Smoking never on 2026-01-13

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 2025-07-18

Chart

More actions

Mei Chen 083

45y | F | English

Priority ,70

needs review

1, flag,

Care team: Maya Singh
Last touch: 2025-07-29

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 CKD surveillance review | high | new | synthetic_longitudinal_data

Chart care elements

BP 133/71 mmHg on 2026-10-22

BP 133/71 mmHg on 2026-10-22 · HbA1c 6.0% on 2026-10-22 · eGFR 45 mL/min/1.73m2 on 2026-10-22 · ACR 4.9 mg/mmol on 2026-10-22 · Smoking never on 2026-10-22

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 2025-07-29

Chart

More actions

5, shown

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

Daniel Brown 064

54y | M | French

Priority ,70

needs review

1, flag,

Care team: Maya Singh
Last touch: 2025-08-02

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

1 open clinical flag

Synthetic BP follow-up review | medium | new | synthetic_longitudinal_data

Chart care elements

BP 142/86 mmHg on 2026-03-03

BP 142/86 mmHg on 2026-03-03 · HbA1c 5.3% on 2026-03-03 · eGFR 81 mL/min/1.73m2 on 2026-03-03 · ACR 1.7 mg/mmol on 2026-03-03 · Smoking never on 2026-03-03

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 2025-08-02

Chart

More actions

Fatima Ali 045

63y | X | English

Priority ,70

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2025-08-06

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

2 open clinical flags

Chart care elements

BP 149/95 mmHg on 2026-08-08

BP 149/95 mmHg on 2026-08-08 · HbA1c 7.3% on 2026-08-08 · eGFR 93 mL/min/1.73m2 on 2026-08-08 · ACR 1.4 mg/mmol on 2026-08-08 · Smoking never on 2026-08-08

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 2025-08-06

Chart

More actions

Lucas Martin 026

72y | M | English

Priority ,70

needs review

1, flag,

Care team: Maya Singh
Last touch: 2025-07-18

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

Synthetic diabetes monitoring review | medium | new | synthetic_longitudinal_data

Chart care elements

BP 124/79 mmHg on 2026-01-13

BP 124/79 mmHg on 2026-01-13 · HbA1c 7.8% on 2026-01-13 · eGFR 74 mL/min/1.73m2 on 2026-01-13 · ACR 1.1 mg/mmol on 2026-01-13 · Smoking never on 2026-01-13

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 2025-07-18

Chart

More actions

Mei Chen 083

45y | F | English

Priority ,70

needs review

1, flag,

Care team: Maya Singh
Last touch: 2025-07-29

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 CKD surveillance review | high | new | synthetic_longitudinal_data

Chart care elements

BP 133/71 mmHg on 2026-10-22

BP 133/71 mmHg on 2026-10-22 · HbA1c 6.0% on 2026-10-22 · eGFR 45 mL/min/1.73m2 on 2026-10-22 · ACR 4.9 mg/mmol on 2026-10-22 · Smoking never on 2026-10-22

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 2025-07-29

Chart

More actions