DocChart

Population Health

PHM worklist

Loading action queue

Loading matching patients, saved rows, and evidence layers.

Building the scoped worklist view

PHM worklist

Possible diabetes signals

Import: docchart_synthetic_population_300.json | Diabetes | showing the first 25 patients for fast loading.
Queue mode: Last saved list.

PHM

Cohort

Ask

Patient scope

Import: docchart_synthetic_population_300.json

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

All patients

70 unique / 403

docchart_synthetic_population_300.json

48 here / 300

docchart_synthetic_population_300.json

48 here / 300

synthetic-100-longitudinal.xml

20 here / 100

sample-omd.xml

None here / 0

What This List Is

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

medium

NLP evidence

Needs review

25, active workflow rows

Queued for:

Possible diabetes signals

How selected:

Deterministic rule + NLP-extracted chart facts + 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 Type 2 diabetes: non-insulin pharmacotherapyCEP Resource 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 ,57

needs review

4, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Angela Steele

19y | F | Tamil

Priority ,57

needs review

2, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Influenza immunization recall | low | in_review | structured_fact · Metformin without diabetes diagnosis | low | new | clinical_note

Chart care elements

BP 124/58 mmHg on 2024-10-29

BP 124/58 mmHg on 2024-10-29 · HbA1c 5.5% on 2025-06-24 · Smoking current smoker on 2025-06-25

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Carla Sherman

50y | F | English

Priority ,57

needs review

2, flag,s

Care team: Melinda Chu
Last touch: 2025-09-08

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 120/79 mmHg on 2024-11-25

BP 120/79 mmHg on 2024-11-25 · HbA1c 6.0% on 2026-04-15 · eGFR 99.0 mL/min/1.73m2 on 2025-08-24 · Smoking never smoker on 2024-12-21

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-09-08

Chart

More actions

Christopher Solis

54y | M | Portuguese

Priority ,57

needs review

3, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Daisy Jones

64y | F | Tamil

Priority ,57

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2026-03-29

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 144/88 mmHg on 2026-04-08

BP 144/88 mmHg on 2026-04-08 · HbA1c 5.9% on 2024-02-02 · eGFR 55.0 mL/min/1.73m2 on 2025-06-16 · ACR 46.6 mg/mmol on 2026-04-13 · Smoking never smoker on 2025-03-22

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Dustin Holt

63y | M | English

Priority ,57

needs review

2, flag,s

Care team: Melinda Chu
Last touch: 2026-03-02

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 130/73 mmHg on 2025-06-26

BP 130/73 mmHg on 2025-06-26 · HbA1c 5.8% on 2025-07-01 · eGFR 94.0 mL/min/1.73m2 on 2025-07-23 · Smoking current smoker on 2025-06-08

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

George Weeks

92y | M | English

Priority ,57

needs review

3, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Jeffrey White

47y | M | Spanish

Priority ,57

needs review

3, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Johnny Johnson

69y | M | English

Priority ,57

needs review

3, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Justin Cunningham

34y | M | Urdu

Priority ,57

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2026-04-25

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

3 open clinical flags

Chart care elements

BP 116/60 mmHg on 2025-03-31

BP 116/60 mmHg on 2025-03-31 · HbA1c 6.3% on 2024-09-20 · Smoking never smoker on 2025-06-13

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2026-04-25

Chart

More actions

Kelsey Thompson

49y | F | English

Priority ,57

needs review

2, flag,s

Care team: Melinda Chu
Last touch: 2025-12-10

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Elevated mental health symptom score | high | new | clinical_note · Metformin without diabetes diagnosis | low | new | clinical_note

Chart care elements

BP 135/77 mmHg on 2025-02-19

BP 135/77 mmHg on 2025-02-19 · HbA1c 5.3% on 2025-12-17 · eGFR 83.0 mL/min/1.73m2 on 2025-10-14 · Smoking never smoker on 2025-03-12

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-12-10

Chart

More actions

Mark Combs

65y | M | Spanish

Priority ,57

needs review

2, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 Baxter

75y | F | French

Priority ,57

needs review

3, flag,s

Care team: Juliana Davies
Last touch: 2025-10-28

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

3 open clinical flags

Chart care elements

BP 134/78 mmHg on 2025-04-25

BP 134/78 mmHg on 2025-04-25 · HbA1c 6.1% on 2026-04-19 · Smoking former smoker on 2024-09-27

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-10-28

Chart

More actions

Mary Rose

85y | F | English

Priority ,57

needs review

3, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Megan Smith

92y | F | English

Priority ,57

needs review

4, flag,s

Care team: Melinda Chu
Last touch: 2026-03-20

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

4 open clinical flags

Chart care elements

BP 111/75 mmHg on 2025-10-02

BP 111/75 mmHg on 2025-10-02 · HbA1c 5.8% on 2026-02-14 · eGFR 97.0 mL/min/1.73m2 on 2023-10-23 · Smoking current smoker on 2026-01-06

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2026-03-20

Chart

More actions

Michael Shelton

40y | M | English

Priority ,57

needs review

2, flag,s

Care team: Amina Farah
Last touch: 2025-04-15

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 122/85 mmHg on 2026-05-12

BP 122/85 mmHg on 2026-05-12 · HbA1c 6.2% on 2026-03-06 · eGFR 83.0 mL/min/1.73m2 on 2024-10-14 · Smoking current smoker on 2025-09-05

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-04-15

Chart

More actions

Michelle Jones

68y | F | English

Priority ,57

needs review

3, flag,s

Care team: Eric Lavoie
Last touch: 2025-05-28

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

3 open clinical flags

Chart care elements

BP 124/80 mmHg on 2026-05-01

BP 124/80 mmHg on 2026-05-01 · HbA1c 5.8% on 2025-05-25 · eGFR 42.0 mL/min/1.73m2 on 2025-04-02 · ACR 92.9 mg/mmol on 2026-05-04 · Smoking former smoker on 2025-11-12

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-05-28

Chart

More actions

Richard Richards

67y | M | French

Priority ,57

needs review

2, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Robert Perez

51y | M | French

Priority ,57

needs review

6, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Russell Reed

31y | M | English

Priority ,57

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2025-05-03

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

3 open clinical flags

Chart care elements

BP 122/78 mmHg on 2023-12-06

BP 122/78 mmHg on 2023-12-06 · HbA1c 5.4% on 2026-03-07 · Smoking former smoker on 2025-07-03

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-05-03

Chart

More actions

Samantha Quinn

50y | F | English

Priority ,57

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2026-06-02

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

3 open clinical flags

Chart care elements

BP 159/99 mmHg on 2026-05-13

BP 159/99 mmHg on 2026-05-13 · HbA1c 5.8% on 2025-08-06 · eGFR 60.0 mL/min/1.73m2 on 2025-12-07 · ACR 8.2 mg/mmol on 2025-03-25 · Smoking never smoker on 2024-12-27

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2026-06-02

Chart

More actions

Stephanie Brown

61y | non-binary | Urdu

Priority ,57

needs review

3, flag,s

Care team: Amina Farah
Last touch: 2026-04-18

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

3 open clinical flags

Chart care elements

BP 149/87 mmHg on 2026-03-09

BP 149/87 mmHg on 2026-03-09 · HbA1c 5.8% on 2025-10-07 · eGFR 75.0 mL/min/1.73m2 on 2026-01-22 · Smoking former smoker on 2026-03-20

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2026-04-18

Chart

More actions

Stephanie Moore

44y | F | Spanish

Priority ,57

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2025-06-08

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 130/70 mmHg on 2025-07-10

BP 130/70 mmHg on 2025-07-10 · HbA1c 5.9% on 2025-08-01 · eGFR 68.0 mL/min/1.73m2 on 2025-01-15 · Smoking former smoker on 2025-12-09

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-06-08

Chart

More actions

Todd Brown

63y | M | English

Priority ,57

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2023-11-14

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 127/83 mmHg on 2026-02-01

BP 127/83 mmHg on 2026-02-01 · HbA1c 6.4% on 2024-07-11 · eGFR 91.0 mL/min/1.73m2 on 2023-12-19 · Smoking not documented on 2025-12-30

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2023-11-14

Chart

More actions

Whitney Miller

56y | F | Spanish

Priority ,57

needs review

2, flag,s

Care team: Amina Farah
Last touch: 2026-02-26

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 144/66 mmHg on 2023-11-01

BP 144/66 mmHg on 2023-11-01 · HbA1c 5.4% on 2024-05-22 · eGFR 49.0 mL/min/1.73m2 on 2026-02-13 · ACR 92.8 mg/mmol on 2026-02-21 · Smoking former smoker on 2024-10-06

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2026-02-26

Chart

More actions

25, shown

Amber Humphrey

84y | F | French

Priority ,57

needs review

4, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Angela Steele

19y | F | Tamil

Priority ,57

needs review

2, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Influenza immunization recall | low | in_review | structured_fact · Metformin without diabetes diagnosis | low | new | clinical_note

Chart care elements

BP 124/58 mmHg on 2024-10-29

BP 124/58 mmHg on 2024-10-29 · HbA1c 5.5% on 2025-06-24 · Smoking current smoker on 2025-06-25

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Carla Sherman

50y | F | English

Priority ,57

needs review

2, flag,s

Care team: Melinda Chu
Last touch: 2025-09-08

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 120/79 mmHg on 2024-11-25

BP 120/79 mmHg on 2024-11-25 · HbA1c 6.0% on 2026-04-15 · eGFR 99.0 mL/min/1.73m2 on 2025-08-24 · Smoking never smoker on 2024-12-21

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-09-08

Chart

More actions

Christopher Solis

54y | M | Portuguese

Priority ,57

needs review

3, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Daisy Jones

64y | F | Tamil

Priority ,57

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2026-03-29

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 144/88 mmHg on 2026-04-08

BP 144/88 mmHg on 2026-04-08 · HbA1c 5.9% on 2024-02-02 · eGFR 55.0 mL/min/1.73m2 on 2025-06-16 · ACR 46.6 mg/mmol on 2026-04-13 · Smoking never smoker on 2025-03-22

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Dustin Holt

63y | M | English

Priority ,57

needs review

2, flag,s

Care team: Melinda Chu
Last touch: 2026-03-02

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 130/73 mmHg on 2025-06-26

BP 130/73 mmHg on 2025-06-26 · HbA1c 5.8% on 2025-07-01 · eGFR 94.0 mL/min/1.73m2 on 2025-07-23 · Smoking current smoker on 2025-06-08

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

George Weeks

92y | M | English

Priority ,57

needs review

3, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Jeffrey White

47y | M | Spanish

Priority ,57

needs review

3, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Johnny Johnson

69y | M | English

Priority ,57

needs review

3, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Justin Cunningham

34y | M | Urdu

Priority ,57

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2026-04-25

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

3 open clinical flags

Chart care elements

BP 116/60 mmHg on 2025-03-31

BP 116/60 mmHg on 2025-03-31 · HbA1c 6.3% on 2024-09-20 · Smoking never smoker on 2025-06-13

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2026-04-25

Chart

More actions

Kelsey Thompson

49y | F | English

Priority ,57

needs review

2, flag,s

Care team: Melinda Chu
Last touch: 2025-12-10

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Elevated mental health symptom score | high | new | clinical_note · Metformin without diabetes diagnosis | low | new | clinical_note

Chart care elements

BP 135/77 mmHg on 2025-02-19

BP 135/77 mmHg on 2025-02-19 · HbA1c 5.3% on 2025-12-17 · eGFR 83.0 mL/min/1.73m2 on 2025-10-14 · Smoking never smoker on 2025-03-12

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-12-10

Chart

More actions

Mark Combs

65y | M | Spanish

Priority ,57

needs review

2, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 Baxter

75y | F | French

Priority ,57

needs review

3, flag,s

Care team: Juliana Davies
Last touch: 2025-10-28

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

3 open clinical flags

Chart care elements

BP 134/78 mmHg on 2025-04-25

BP 134/78 mmHg on 2025-04-25 · HbA1c 6.1% on 2026-04-19 · Smoking former smoker on 2024-09-27

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-10-28

Chart

More actions

Mary Rose

85y | F | English

Priority ,57

needs review

3, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Megan Smith

92y | F | English

Priority ,57

needs review

4, flag,s

Care team: Melinda Chu
Last touch: 2026-03-20

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

4 open clinical flags

Chart care elements

BP 111/75 mmHg on 2025-10-02

BP 111/75 mmHg on 2025-10-02 · HbA1c 5.8% on 2026-02-14 · eGFR 97.0 mL/min/1.73m2 on 2023-10-23 · Smoking current smoker on 2026-01-06

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2026-03-20

Chart

More actions

Michael Shelton

40y | M | English

Priority ,57

needs review

2, flag,s

Care team: Amina Farah
Last touch: 2025-04-15

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 122/85 mmHg on 2026-05-12

BP 122/85 mmHg on 2026-05-12 · HbA1c 6.2% on 2026-03-06 · eGFR 83.0 mL/min/1.73m2 on 2024-10-14 · Smoking current smoker on 2025-09-05

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-04-15

Chart

More actions

Michelle Jones

68y | F | English

Priority ,57

needs review

3, flag,s

Care team: Eric Lavoie
Last touch: 2025-05-28

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

3 open clinical flags

Chart care elements

BP 124/80 mmHg on 2026-05-01

BP 124/80 mmHg on 2026-05-01 · HbA1c 5.8% on 2025-05-25 · eGFR 42.0 mL/min/1.73m2 on 2025-04-02 · ACR 92.9 mg/mmol on 2026-05-04 · Smoking former smoker on 2025-11-12

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-05-28

Chart

More actions

Richard Richards

67y | M | French

Priority ,57

needs review

2, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Robert Perez

51y | M | French

Priority ,57

needs review

6, flag,s

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

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

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 (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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

Russell Reed

31y | M | English

Priority ,57

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2025-05-03

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

3 open clinical flags

Chart care elements

BP 122/78 mmHg on 2023-12-06

BP 122/78 mmHg on 2023-12-06 · HbA1c 5.4% on 2026-03-07 · Smoking former smoker on 2025-07-03

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-05-03

Chart

More actions

Samantha Quinn

50y | F | English

Priority ,57

needs review

3, flag,s

Care team: Wole Oduntan
Last touch: 2026-06-02

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

3 open clinical flags

Chart care elements

BP 159/99 mmHg on 2026-05-13

BP 159/99 mmHg on 2026-05-13 · HbA1c 5.8% on 2025-08-06 · eGFR 60.0 mL/min/1.73m2 on 2025-12-07 · ACR 8.2 mg/mmol on 2025-03-25 · Smoking never smoker on 2024-12-27

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2026-06-02

Chart

More actions

Stephanie Brown

61y | non-binary | Urdu

Priority ,57

needs review

3, flag,s

Care team: Amina Farah
Last touch: 2026-04-18

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

3 open clinical flags

Chart care elements

BP 149/87 mmHg on 2026-03-09

BP 149/87 mmHg on 2026-03-09 · HbA1c 5.8% on 2025-10-07 · eGFR 75.0 mL/min/1.73m2 on 2026-01-22 · Smoking former smoker on 2026-03-20

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2026-04-18

Chart

More actions

Stephanie Moore

44y | F | Spanish

Priority ,57

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2025-06-08

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 130/70 mmHg on 2025-07-10

BP 130/70 mmHg on 2025-07-10 · HbA1c 5.9% on 2025-08-01 · eGFR 68.0 mL/min/1.73m2 on 2025-01-15 · Smoking former smoker on 2025-12-09

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2025-06-08

Chart

More actions

Todd Brown

63y | M | English

Priority ,57

needs review

2, flag,s

Care team: Eric Lavoie
Last touch: 2023-11-14

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 127/83 mmHg on 2026-02-01

BP 127/83 mmHg on 2026-02-01 · HbA1c 6.4% on 2024-07-11 · eGFR 91.0 mL/min/1.73m2 on 2023-12-19 · Smoking not documented on 2025-12-30

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2023-11-14

Chart

More actions

Whitney Miller

56y | F | Spanish

Priority ,57

needs review

2, flag,s

Care team: Amina Farah
Last touch: 2026-02-26

6 evidence layers

NLP evidence

DocChart PHM rule

Possible diabetes signals 2026.05

Prediabetes, note text or medication pattern without confirmed diabetes criteria.

DocChart flags

2 open clinical flags

Chart care elements

BP 144/66 mmHg on 2023-11-01

BP 144/66 mmHg on 2023-11-01 · HbA1c 5.4% on 2024-05-22 · eGFR 49.0 mL/min/1.73m2 on 2026-02-13 · ACR 92.8 mg/mmol on 2026-02-21 · Smoking former smoker on 2024-10-06

Evidence details (4)

NLP evidence layer

NLP extraction enabled for this rule

No extracted fact was required for this row; structured chart data and flags still matched.

AI-CDS guidance

1 Quality Standard / 1 CEP resource

Prediabetes and Type 2 Diabetes · Type 2 diabetes: non-insulin pharmacotherapy

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 2026-02-26

Chart

More actions