DocChart

Population Health

PHM worklist

Loading action queue

Loading matching patients, saved rows, and evidence layers.

Building the scoped worklist view

PHM worklist

Uncontrolled blood pressure

Import: synthetic-100-longitudinal.xml | Hypertension | showing the first 25 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

103 unique / 403

docchart_synthetic_population_300.json

60 here / 300

docchart_synthetic_population_300.json

60 here / 300

synthetic-100-longitudinal.xml

43 here / 100

sample-omd.xml

None here / 0

What This List Is

Recent BP values are above configured threshold.

high

Structured fact

Needs review

25, active workflow rows

Queued for:

Uncontrolled blood pressure

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.

HypertensionQuality Standard linked through AI-CDS guidance retrieval

Patients

Showing 25 of 25 visible rows from 25 matched patients.

25, shown

Daniel Brown 064

54y | M | French

Priority ,100

needs review

1, flag,

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

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

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

Hypertension

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 ,100

needs review

2, flag,s

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

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

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

Hypertension

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

Aisha Khan 001

83y | F | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-16

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 157/93 mmHg on 2026-12-12

BP 157/93 mmHg on 2026-12-12 · HbA1c 7.7% on 2026-12-12 · eGFR 80 mL/min/1.73m2 on 2026-12-12 · ACR 1.8 mg/mmol on 2026-12-12 · Smoking never on 2026-12-12

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-16

Chart

More actions

Fatima Ali 025

72y | F | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-17

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 155/89 mmHg on 2026-12-12

BP 155/89 mmHg on 2026-12-12 · HbA1c 7.7% on 2026-12-12 · eGFR 73 mL/min/1.73m2 on 2026-12-12 · ACR 1.0 mg/mmol on 2026-12-12 · Smoking never on 2026-12-12

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-17

Chart

More actions

Grace Thompson 057

57y | X | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-26

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 135/93 mmHg on 2026-08-20

BP 135/93 mmHg on 2026-08-20 · HbA1c 8.5% on 2026-08-20 · eGFR 74 mL/min/1.73m2 on 2026-08-20 · ACR 1.0 mg/mmol on 2026-08-20 · Smoking never on 2026-08-20

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-26

Chart

More actions

Grace Thompson 077

47y | F | Mandarin

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-23

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 155/85 mmHg on 2026-04-16

BP 155/85 mmHg on 2026-04-16 · HbA1c 8.1% on 2026-04-16 · eGFR 94 mL/min/1.73m2 on 2026-04-16 · ACR 1.4 mg/mmol on 2026-04-16 · Smoking current on 2026-04-16

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-23

Chart

More actions

Grace Thompson 097

38y | F | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-20

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 149/91 mmHg on 2026-12-12

BP 149/91 mmHg on 2026-12-12 · HbA1c 7.7% on 2026-12-12 · eGFR 83 mL/min/1.73m2 on 2026-12-12 · ACR 1.8 mg/mmol on 2026-12-12 · Smoking never on 2026-12-12

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-20

Chart

More actions

Jacob Walker 020

74y | M | English

Priority ,90

needs review

3, flag,s

Care team: Maya Singh
Last touch: 2026-02-04

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

3 open clinical flags

Chart care elements

BP 150/84 mmHg on 2026-07-07

BP 150/84 mmHg on 2026-07-07 · HbA1c 7.2% on 2026-07-07 · eGFR 54 mL/min/1.73m2 on 2026-07-07 · ACR 4.6 mg/mmol on 2026-07-07 · Smoking never on 2026-07-07

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-02-04

Chart

More actions

Jacob Walker 040

65y | M | French

Priority ,90

needs review

3, flag,s

Care team: Maya Singh
Last touch: 2026-02-01

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

3 open clinical flags

Chart care elements

BP 144/90 mmHg on 2026-03-03

BP 144/90 mmHg on 2026-03-03 · HbA1c 6.8% on 2026-03-03 · eGFR 56 mL/min/1.73m2 on 2026-03-03 · ACR 6.6 mg/mmol on 2026-03-03 · Smoking never on 2026-03-03

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-02-01

Chart

More actions

Jacob Walker 060

56y | X | English

Priority ,90

needs review

3, flag,s

Care team: Maya Singh
Last touch: 2026-01-29

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

3 open clinical flags

Chart care elements

BP 138/82 mmHg on 2026-11-23

BP 138/82 mmHg on 2026-11-23 · HbA1c 8.8% on 2026-11-23 · eGFR 58 mL/min/1.73m2 on 2026-11-23 · ACR 8.6 mg/mmol on 2026-11-23 · Smoking former on 2026-11-23

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-29

Chart

More actions

Jacob Walker 080

46y | M | French

Priority ,90

needs review

3, flag,s

Care team: Maya Singh
Last touch: 2026-01-26

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

3 open clinical flags

Chart care elements

BP 132/88 mmHg on 2026-07-19

BP 132/88 mmHg on 2026-07-19 · HbA1c 8.4% on 2026-07-19 · eGFR 42 mL/min/1.73m2 on 2026-07-19 · ACR 4.6 mg/mmol on 2026-07-19 · Smoking never on 2026-07-19

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-26

Chart

More actions

Jacob Walker 100

37y | M | English

Priority ,90

needs review

3, flag,s

Care team: Maya Singh
Last touch: 2026-01-23

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

3 open clinical flags

Chart care elements

BP 152/94 mmHg on 2026-03-15

BP 152/94 mmHg on 2026-03-15 · HbA1c 8.0% on 2026-03-15 · eGFR 44 mL/min/1.73m2 on 2026-03-15 · ACR 6.6 mg/mmol on 2026-03-15 · Smoking never on 2026-03-15

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-23

Chart

More actions

Maya Singh 013

78y | F | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-28

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 143/91 mmHg on 2026-12-24

BP 143/91 mmHg on 2026-12-24 · HbA1c 6.2% on 2026-12-24 · eGFR 47 mL/min/1.73m2 on 2026-12-24 · ACR 9.9 mg/mmol on 2026-12-24 · Smoking never on 2026-12-24

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-28

Chart

More actions

Maya Singh 053

59y | F | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-22

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 157/89 mmHg on 2026-04-16

BP 157/89 mmHg on 2026-04-16 · HbA1c 5.4% on 2026-04-16 · eGFR 51 mL/min/1.73m2 on 2026-04-16 · ACR 7.9 mg/mmol on 2026-04-16 · Smoking never on 2026-04-16

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-22

Chart

More actions

Maya Singh 073

49y | F | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-19

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 151/95 mmHg on 2026-12-12

BP 151/95 mmHg on 2026-12-12 · HbA1c 6.2% on 2026-12-12 · eGFR 53 mL/min/1.73m2 on 2026-12-12 · ACR 9.9 mg/mmol on 2026-12-12 · Smoking never on 2026-12-12

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-19

Chart

More actions

Maya Singh 093

40y | X | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-16

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 145/87 mmHg on 2026-08-08

BP 145/87 mmHg on 2026-08-08 · HbA1c 5.8% on 2026-08-08 · eGFR 55 mL/min/1.73m2 on 2026-08-08 · ACR 5.9 mg/mmol on 2026-08-08 · Smoking never on 2026-08-08

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-16

Chart

More actions

Noah Taylor 012

78y | X | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-27

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 142/90 mmHg on 2026-11-23

BP 142/90 mmHg on 2026-11-23 · HbA1c 8.8% on 2026-11-23 · eGFR 91 mL/min/1.73m2 on 2026-11-23 · ACR 1.3 mg/mmol on 2026-11-23 · Smoking former on 2026-11-23

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-27

Chart

More actions

Noah Taylor 032

69y | M | French

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-24

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 136/82 mmHg on 2026-07-19

BP 136/82 mmHg on 2026-07-19 · HbA1c 8.4% on 2026-07-19 · eGFR 80 mL/min/1.73m2 on 2026-07-19 · ACR 1.7 mg/mmol on 2026-07-19 · Smoking never on 2026-07-19

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-24

Chart

More actions

Noah Taylor 052

59y | M | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-21

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 156/88 mmHg on 2026-03-15

BP 156/88 mmHg on 2026-03-15 · HbA1c 8.0% on 2026-03-15 · eGFR 69 mL/min/1.73m2 on 2026-03-15 · ACR 2.1 mg/mmol on 2026-03-15 · Smoking never on 2026-03-15

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-21

Chart

More actions

Noah Taylor 072

50y | X | French

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-18

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 150/94 mmHg on 2026-11-11

BP 150/94 mmHg on 2026-11-11 · HbA1c 7.6% on 2026-11-11 · eGFR 89 mL/min/1.73m2 on 2026-11-11 · ACR 0.9 mg/mmol on 2026-11-11 · Smoking former on 2026-11-11

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-18

Chart

More actions

Noah Taylor 092

40y | M | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-15

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 144/86 mmHg on 2026-07-07

BP 144/86 mmHg on 2026-07-07 · HbA1c 7.2% on 2026-07-07 · eGFR 78 mL/min/1.73m2 on 2026-07-07 · ACR 1.3 mg/mmol on 2026-07-07 · Smoking never on 2026-07-07

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-15

Chart

More actions

Ravi Shah 036

67y | X | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-28

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 140/86 mmHg on 2026-11-23

BP 140/86 mmHg on 2026-11-23 · HbA1c 8.8% on 2026-11-23 · eGFR 84 mL/min/1.73m2 on 2026-11-23 · ACR 2.1 mg/mmol on 2026-11-23 · Smoking former on 2026-11-23

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-28

Chart

More actions

Ravi Shah 056

57y | M | French

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-25

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 134/92 mmHg on 2026-07-19

BP 134/92 mmHg on 2026-07-19 · HbA1c 8.4% on 2026-07-19 · eGFR 73 mL/min/1.73m2 on 2026-07-19 · ACR 0.9 mg/mmol on 2026-07-19 · Smoking never on 2026-07-19

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-25

Chart

More actions

Ravi Shah 076

48y | M | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-22

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 154/84 mmHg on 2026-03-15

BP 154/84 mmHg on 2026-03-15 · HbA1c 8.0% on 2026-03-15 · eGFR 93 mL/min/1.73m2 on 2026-03-15 · ACR 1.3 mg/mmol on 2026-03-15 · Smoking never on 2026-03-15

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-22

Chart

More actions

Ravi Shah 096

38y | X | French

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-19

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 148/90 mmHg on 2026-11-11

BP 148/90 mmHg on 2026-11-11 · HbA1c 7.6% on 2026-11-11 · eGFR 82 mL/min/1.73m2 on 2026-11-11 · ACR 1.7 mg/mmol on 2026-11-11 · Smoking former on 2026-11-11

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-19

Chart

More actions

25, shown

Daniel Brown 064

54y | M | French

Priority ,100

needs review

1, flag,

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

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

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

Hypertension

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 ,100

needs review

2, flag,s

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

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

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

Hypertension

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

Aisha Khan 001

83y | F | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-16

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 157/93 mmHg on 2026-12-12

BP 157/93 mmHg on 2026-12-12 · HbA1c 7.7% on 2026-12-12 · eGFR 80 mL/min/1.73m2 on 2026-12-12 · ACR 1.8 mg/mmol on 2026-12-12 · Smoking never on 2026-12-12

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-16

Chart

More actions

Fatima Ali 025

72y | F | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-17

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 155/89 mmHg on 2026-12-12

BP 155/89 mmHg on 2026-12-12 · HbA1c 7.7% on 2026-12-12 · eGFR 73 mL/min/1.73m2 on 2026-12-12 · ACR 1.0 mg/mmol on 2026-12-12 · Smoking never on 2026-12-12

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-17

Chart

More actions

Grace Thompson 057

57y | X | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-26

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 135/93 mmHg on 2026-08-20

BP 135/93 mmHg on 2026-08-20 · HbA1c 8.5% on 2026-08-20 · eGFR 74 mL/min/1.73m2 on 2026-08-20 · ACR 1.0 mg/mmol on 2026-08-20 · Smoking never on 2026-08-20

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-26

Chart

More actions

Grace Thompson 077

47y | F | Mandarin

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-23

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 155/85 mmHg on 2026-04-16

BP 155/85 mmHg on 2026-04-16 · HbA1c 8.1% on 2026-04-16 · eGFR 94 mL/min/1.73m2 on 2026-04-16 · ACR 1.4 mg/mmol on 2026-04-16 · Smoking current on 2026-04-16

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-23

Chart

More actions

Grace Thompson 097

38y | F | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-20

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 149/91 mmHg on 2026-12-12

BP 149/91 mmHg on 2026-12-12 · HbA1c 7.7% on 2026-12-12 · eGFR 83 mL/min/1.73m2 on 2026-12-12 · ACR 1.8 mg/mmol on 2026-12-12 · Smoking never on 2026-12-12

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-20

Chart

More actions

Jacob Walker 020

74y | M | English

Priority ,90

needs review

3, flag,s

Care team: Maya Singh
Last touch: 2026-02-04

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

3 open clinical flags

Chart care elements

BP 150/84 mmHg on 2026-07-07

BP 150/84 mmHg on 2026-07-07 · HbA1c 7.2% on 2026-07-07 · eGFR 54 mL/min/1.73m2 on 2026-07-07 · ACR 4.6 mg/mmol on 2026-07-07 · Smoking never on 2026-07-07

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-02-04

Chart

More actions

Jacob Walker 040

65y | M | French

Priority ,90

needs review

3, flag,s

Care team: Maya Singh
Last touch: 2026-02-01

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

3 open clinical flags

Chart care elements

BP 144/90 mmHg on 2026-03-03

BP 144/90 mmHg on 2026-03-03 · HbA1c 6.8% on 2026-03-03 · eGFR 56 mL/min/1.73m2 on 2026-03-03 · ACR 6.6 mg/mmol on 2026-03-03 · Smoking never on 2026-03-03

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-02-01

Chart

More actions

Jacob Walker 060

56y | X | English

Priority ,90

needs review

3, flag,s

Care team: Maya Singh
Last touch: 2026-01-29

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

3 open clinical flags

Chart care elements

BP 138/82 mmHg on 2026-11-23

BP 138/82 mmHg on 2026-11-23 · HbA1c 8.8% on 2026-11-23 · eGFR 58 mL/min/1.73m2 on 2026-11-23 · ACR 8.6 mg/mmol on 2026-11-23 · Smoking former on 2026-11-23

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-29

Chart

More actions

Jacob Walker 080

46y | M | French

Priority ,90

needs review

3, flag,s

Care team: Maya Singh
Last touch: 2026-01-26

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

3 open clinical flags

Chart care elements

BP 132/88 mmHg on 2026-07-19

BP 132/88 mmHg on 2026-07-19 · HbA1c 8.4% on 2026-07-19 · eGFR 42 mL/min/1.73m2 on 2026-07-19 · ACR 4.6 mg/mmol on 2026-07-19 · Smoking never on 2026-07-19

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-26

Chart

More actions

Jacob Walker 100

37y | M | English

Priority ,90

needs review

3, flag,s

Care team: Maya Singh
Last touch: 2026-01-23

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

3 open clinical flags

Chart care elements

BP 152/94 mmHg on 2026-03-15

BP 152/94 mmHg on 2026-03-15 · HbA1c 8.0% on 2026-03-15 · eGFR 44 mL/min/1.73m2 on 2026-03-15 · ACR 6.6 mg/mmol on 2026-03-15 · Smoking never on 2026-03-15

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-23

Chart

More actions

Maya Singh 013

78y | F | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-28

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 143/91 mmHg on 2026-12-24

BP 143/91 mmHg on 2026-12-24 · HbA1c 6.2% on 2026-12-24 · eGFR 47 mL/min/1.73m2 on 2026-12-24 · ACR 9.9 mg/mmol on 2026-12-24 · Smoking never on 2026-12-24

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-28

Chart

More actions

Maya Singh 053

59y | F | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-22

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 157/89 mmHg on 2026-04-16

BP 157/89 mmHg on 2026-04-16 · HbA1c 5.4% on 2026-04-16 · eGFR 51 mL/min/1.73m2 on 2026-04-16 · ACR 7.9 mg/mmol on 2026-04-16 · Smoking never on 2026-04-16

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-22

Chart

More actions

Maya Singh 073

49y | F | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-19

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 151/95 mmHg on 2026-12-12

BP 151/95 mmHg on 2026-12-12 · HbA1c 6.2% on 2026-12-12 · eGFR 53 mL/min/1.73m2 on 2026-12-12 · ACR 9.9 mg/mmol on 2026-12-12 · Smoking never on 2026-12-12

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-19

Chart

More actions

Maya Singh 093

40y | X | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-16

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 145/87 mmHg on 2026-08-08

BP 145/87 mmHg on 2026-08-08 · HbA1c 5.8% on 2026-08-08 · eGFR 55 mL/min/1.73m2 on 2026-08-08 · ACR 5.9 mg/mmol on 2026-08-08 · Smoking never on 2026-08-08

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-16

Chart

More actions

Noah Taylor 012

78y | X | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-27

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 142/90 mmHg on 2026-11-23

BP 142/90 mmHg on 2026-11-23 · HbA1c 8.8% on 2026-11-23 · eGFR 91 mL/min/1.73m2 on 2026-11-23 · ACR 1.3 mg/mmol on 2026-11-23 · Smoking former on 2026-11-23

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-27

Chart

More actions

Noah Taylor 032

69y | M | French

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-24

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 136/82 mmHg on 2026-07-19

BP 136/82 mmHg on 2026-07-19 · HbA1c 8.4% on 2026-07-19 · eGFR 80 mL/min/1.73m2 on 2026-07-19 · ACR 1.7 mg/mmol on 2026-07-19 · Smoking never on 2026-07-19

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-24

Chart

More actions

Noah Taylor 052

59y | M | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-21

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 156/88 mmHg on 2026-03-15

BP 156/88 mmHg on 2026-03-15 · HbA1c 8.0% on 2026-03-15 · eGFR 69 mL/min/1.73m2 on 2026-03-15 · ACR 2.1 mg/mmol on 2026-03-15 · Smoking never on 2026-03-15

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-21

Chart

More actions

Noah Taylor 072

50y | X | French

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-18

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 150/94 mmHg on 2026-11-11

BP 150/94 mmHg on 2026-11-11 · HbA1c 7.6% on 2026-11-11 · eGFR 89 mL/min/1.73m2 on 2026-11-11 · ACR 0.9 mg/mmol on 2026-11-11 · Smoking former on 2026-11-11

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-18

Chart

More actions

Noah Taylor 092

40y | M | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-15

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 144/86 mmHg on 2026-07-07

BP 144/86 mmHg on 2026-07-07 · HbA1c 7.2% on 2026-07-07 · eGFR 78 mL/min/1.73m2 on 2026-07-07 · ACR 1.3 mg/mmol on 2026-07-07 · Smoking never on 2026-07-07

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-15

Chart

More actions

Ravi Shah 036

67y | X | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-28

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 140/86 mmHg on 2026-11-23

BP 140/86 mmHg on 2026-11-23 · HbA1c 8.8% on 2026-11-23 · eGFR 84 mL/min/1.73m2 on 2026-11-23 · ACR 2.1 mg/mmol on 2026-11-23 · Smoking former on 2026-11-23

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-28

Chart

More actions

Ravi Shah 056

57y | M | French

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-25

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 134/92 mmHg on 2026-07-19

BP 134/92 mmHg on 2026-07-19 · HbA1c 8.4% on 2026-07-19 · eGFR 73 mL/min/1.73m2 on 2026-07-19 · ACR 0.9 mg/mmol on 2026-07-19 · Smoking never on 2026-07-19

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-25

Chart

More actions

Ravi Shah 076

48y | M | English

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-22

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 154/84 mmHg on 2026-03-15

BP 154/84 mmHg on 2026-03-15 · HbA1c 8.0% on 2026-03-15 · eGFR 93 mL/min/1.73m2 on 2026-03-15 · ACR 1.3 mg/mmol on 2026-03-15 · Smoking never on 2026-03-15

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-22

Chart

More actions

Ravi Shah 096

38y | X | French

Priority ,90

needs review

2, flag,s

Care team: Maya Singh
Last touch: 2026-01-19

5 evidence layers

Structured fact

DocChart PHM rule

Uncontrolled blood pressure 2026.05

Recent BP values are above configured threshold.

DocChart flags

2 open clinical flags

Chart care elements

BP 148/90 mmHg on 2026-11-11

BP 148/90 mmHg on 2026-11-11 · HbA1c 7.6% on 2026-11-11 · eGFR 82 mL/min/1.73m2 on 2026-11-11 · ACR 1.7 mg/mmol on 2026-11-11 · Smoking former on 2026-11-11

Evidence details (3)

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Hypertension

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 2026-01-19

Chart

More actions