{ "样例性质": "真实记录·已脱敏", "inpatient_case": { "admission_time_raw": "2026-07-14 13:46", "case_id": "CASE-0000001", "case_status": "source_single_inpatient_case", "discharge_time_raw": "2026-07-29 08:08" }, "homepage": { "admission_time_raw": "2026-07-14 13:46", "case_id": "CASE-0000001", "diagnosis_raw": "1.直肠癌（T1N1M0 ⅢA期） \n2.低蛋白血症；高血压；动脉粥样硬化；胆囊多发结石并慢性胆囊炎；胆总管内多发小结石；肾结石；肾囊肿", "discharge_time_raw": "2026-07-29 08:08", "homepage_id": "DOC-0000001", "procedure_raw": "1.腹腔镜下直肠前切除术+回肠预防性单腔造口术" }, "diagnosis_source_field": [ { "case_id": "CASE-0000001", "field_id": "FIELD-0000001", "slice_count": "1", "source_field": "homepage_emergency_diagnosis", "source_raw": "直肠肿物" }, { "case_id": "CASE-0000001", "field_id": "FIELD-0000002", "slice_count": "7", "source_field": "homepage_discharge_diagnosis", "source_raw": "1.直肠癌（T1N1M0 ⅢA期） \n2.低蛋白血症；高血压；动脉粥样硬化；胆囊多发结石并慢性胆囊炎；胆总管内多发小结石；肾结石；肾囊肿" }, { "case_id": "CASE-0000001", "field_id": "FIELD-0000003", "slice_count": "5", "source_field": "outpatient_diagnosis", "source_raw": "直肠肿物,大便习惯改变,内痔,外痔,高血压" }, { "case_id": "CASE-0000001", "field_id": "FIELD-0000004", "slice_count": "1", "source_field": "admission_diagnosis", "source_raw": "初步诊断：\n西医诊断\n1.直肠肿物\n2.高血压\n修正诊断：\n西医诊断：\n1.直肠癌\n2.低蛋白血症\n3.高血压\n4.动脉粥样硬化\n5.胆囊结石伴慢性胆囊炎\n6.胆总管结石\n7.肾结石\n8.单纯性肾囊肿" }, { "case_id": "CASE-0000001", "field_id": "FIELD-0000005", "slice_count": "1", "source_field": "first_course_diagnosis", "source_raw": "直肠肿物 高血压" }, { "case_id": "CASE-0000001", "field_id": "FIELD-0000006", "slice_count": "7", "source_field": "procedure_pre_diagnosis", "source_raw": "直肠癌；高血压；动脉粥样硬化；胆囊多发结石并慢性胆囊炎；胆总管内多发小结石；肾结石；肾囊肿2026-07-20 09:00 2026-07-20 11:50" }, { "case_id": "CASE-0000001", "field_id": "FIELD-0000007", "slice_count": "7", "source_field": "procedure_post_diagnosis", "source_raw": "直肠癌；高血压；动脉粥样硬化；胆囊多发结石并慢性胆囊炎；胆总管内多发小结石；肾结石；肾囊肿" }, { "case_id": "CASE-0000001", "field_id": "FIELD-0000008", "slice_count": "2", "source_field": "discharge_admission_diagnosis", "source_raw": "直肠肿物；高血压" }, { "case_id": "CASE-0000001", "field_id": "FIELD-0000009", "slice_count": "7", "source_field": "discharge_diagnosis", "source_raw": "主要诊断：直肠癌（T1N1M0 ⅢA期） 次要诊断：低蛋白血症；高血压；动脉粥样硬化；胆囊多发结石并慢性胆囊炎；胆总管内多发小结石；肾结石；肾囊肿。" } ], "diagnosis_slice": [ { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000001", "diagnosis_raw": "直肠肿物", "field_id": "FIELD-0000001", "mapping_status": "raw_not_standardized", "slice_no": "1" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000002", "diagnosis_raw": "1.直肠癌（T1N1M0 ⅢA期） \n2.低蛋白血症", "field_id": "FIELD-0000002", "mapping_status": "raw_not_standardized", "slice_no": "1" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000003", "diagnosis_raw": "高血压", "field_id": "FIELD-0000002", "mapping_status": "raw_not_standardized", "slice_no": "2" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000004", "diagnosis_raw": "动脉粥样硬化", "field_id": "FIELD-0000002", "mapping_status": "raw_not_standardized", "slice_no": "3" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000005", "diagnosis_raw": "胆囊多发结石并慢性胆囊炎", "field_id": "FIELD-0000002", "mapping_status": "raw_not_standardized", "slice_no": "4" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000006", "diagnosis_raw": "胆总管内多发小结石", "field_id": "FIELD-0000002", "mapping_status": "raw_not_standardized", "slice_no": "5" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000007", "diagnosis_raw": "肾结石", "field_id": "FIELD-0000002", "mapping_status": "raw_not_standardized", "slice_no": "6" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000008", "diagnosis_raw": "肾囊肿", "field_id": "FIELD-0000002", "mapping_status": "raw_not_standardized", "slice_no": "7" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000009", "diagnosis_raw": "直肠肿物", "field_id": "FIELD-0000003", "mapping_status": "raw_not_standardized", "slice_no": "1" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000010", "diagnosis_raw": "大便习惯改变", "field_id": "FIELD-0000003", "mapping_status": "raw_not_standardized", "slice_no": "2" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000011", "diagnosis_raw": "内痔", "field_id": "FIELD-0000003", "mapping_status": "raw_not_standardized", "slice_no": "3" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000012", "diagnosis_raw": "外痔", "field_id": "FIELD-0000003", "mapping_status": "raw_not_standardized", "slice_no": "4" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000013", "diagnosis_raw": "高血压", "field_id": "FIELD-0000003", "mapping_status": "raw_not_standardized", "slice_no": "5" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000014", "diagnosis_raw": "初步诊断：\n西医诊断\n1.直肠肿物\n2.高血压\n修正诊断：\n西医诊断：\n1.直肠癌\n2.低蛋白血症\n3.高血压\n4.动脉粥样硬化\n5.胆囊结石伴慢性胆囊炎\n6.胆总管结石\n7.肾结石\n8.单纯性肾囊肿", "field_id": "FIELD-0000004", "mapping_status": "raw_not_standardized", "slice_no": "1" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000015", "diagnosis_raw": "直肠肿物 高血压", "field_id": "FIELD-0000005", "mapping_status": "raw_not_standardized", "slice_no": "1" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000016", "diagnosis_raw": "直肠癌", "field_id": "FIELD-0000006", "mapping_status": "raw_not_standardized", "slice_no": "1" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000017", "diagnosis_raw": "高血压", "field_id": "FIELD-0000006", "mapping_status": "raw_not_standardized", "slice_no": "2" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000018", "diagnosis_raw": "动脉粥样硬化", "field_id": "FIELD-0000006", "mapping_status": "raw_not_standardized", "slice_no": "3" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000019", "diagnosis_raw": "胆囊多发结石并慢性胆囊炎", "field_id": "FIELD-0000006", "mapping_status": "raw_not_standardized", "slice_no": "4" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000020", "diagnosis_raw": "胆总管内多发小结石", "field_id": "FIELD-0000006", "mapping_status": "raw_not_standardized", "slice_no": "5" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000021", "diagnosis_raw": "肾结石", "field_id": "FIELD-0000006", "mapping_status": "raw_not_standardized", "slice_no": "6" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000022", "diagnosis_raw": "肾囊肿2026-07-20 09:00 2026-07-20 11:50", "field_id": "FIELD-0000006", "mapping_status": "raw_not_standardized", "slice_no": "7" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000023", "diagnosis_raw": "直肠癌", "field_id": "FIELD-0000007", "mapping_status": "raw_not_standardized", "slice_no": "1" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000024", "diagnosis_raw": "高血压", "field_id": "FIELD-0000007", "mapping_status": "raw_not_standardized", "slice_no": "2" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000025", "diagnosis_raw": "动脉粥样硬化", "field_id": "FIELD-0000007", "mapping_status": "raw_not_standardized", "slice_no": "3" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000026", "diagnosis_raw": "胆囊多发结石并慢性胆囊炎", "field_id": "FIELD-0000007", "mapping_status": "raw_not_standardized", "slice_no": "4" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000027", "diagnosis_raw": "胆总管内多发小结石", "field_id": "FIELD-0000007", "mapping_status": "raw_not_standardized", "slice_no": "5" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000028", "diagnosis_raw": "肾结石", "field_id": "FIELD-0000007", "mapping_status": "raw_not_standardized", "slice_no": "6" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000029", "diagnosis_raw": "肾囊肿", "field_id": "FIELD-0000007", "mapping_status": "raw_not_standardized", "slice_no": "7" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000030", "diagnosis_raw": "直肠肿物", "field_id": "FIELD-0000008", "mapping_status": "raw_not_standardized", "slice_no": "1" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000031", "diagnosis_raw": "高血压", "field_id": "FIELD-0000008", "mapping_status": "raw_not_standardized", "slice_no": "2" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000032", "diagnosis_raw": "主要诊断：直肠癌（T1N1M0 ⅢA期） 次要诊断：低蛋白血症", "field_id": "FIELD-0000009", "mapping_status": "raw_not_standardized", "slice_no": "1" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000033", "diagnosis_raw": "高血压", "field_id": "FIELD-0000009", "mapping_status": "raw_not_standardized", "slice_no": "2" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000034", "diagnosis_raw": "动脉粥样硬化", "field_id": "FIELD-0000009", "mapping_status": "raw_not_standardized", "slice_no": "3" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000035", "diagnosis_raw": "胆囊多发结石并慢性胆囊炎", "field_id": "FIELD-0000009", "mapping_status": "raw_not_standardized", "slice_no": "4" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000036", "diagnosis_raw": "胆总管内多发小结石", "field_id": "FIELD-0000009", "mapping_status": "raw_not_standardized", "slice_no": "5" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000037", "diagnosis_raw": "肾结石", "field_id": "FIELD-0000009", "mapping_status": "raw_not_standardized", "slice_no": "6" }, { "case_id": "CASE-0000001", "diagnosis_id": "DIAGNOSIS-0000038", "diagnosis_raw": "肾囊肿。", "field_id": "FIELD-0000009", "mapping_status": "raw_not_standardized", "slice_no": "7" } ], "procedure_record": [ { "actual_end_time_raw": "2026-07-20 11:50:00", "actual_start_time_raw": "2026-07-20 09:00:00", "case_id": "CASE-0000001", "implementation_status": "performed_source_record", "procedure_id": "PROCEDURE-0000001", "procedure_name_raw": "腹腔镜下直肠前切除术+回肠预防性单腔造口术" } ], "discharge_outcome": { "case_id": "CASE-0000001", "discharge_time_raw": "2026-07-29 08:08:16", "outcome_id": "OUTCOME-0000001", "outcome_raw": "现患者精神、睡眠、饮食可，无畏寒发热，无恶心呕吐，无胸痛胸闷，无腹胀腹痛等不适，造瘘口正常排气排便，小便可。查体：心肺未见明显异常，腹部软，无明显压痛、反跳痛及肌紧张，腹部切口愈合可，未拆线。造瘘口粘膜红润、通畅。患者一般情况可，今日出院。", "outcome_status": "source_discharge_outcome_not_long_term" }, "quality_issue": { "handling": "no expense, verified code mapping or case version inferred", "issue_code": "expense_mapping_and_version_zero", "quality_issue_id": "REAL_QI_001" } }