{
  "样例性质": "真实记录·已脱敏",
  "regimen_definition": {
    "definition_status": "draft_project_defined_not_guideline_standard",
    "regimen_definition_id": "REGIMEN_DEFINITION-0000001",
    "regimen_name": "source procedure regimen",
    "version": "source_procedure_regimen_v0.1"
  },
  "regimen_component": {
    "component_id": "COMPONENT-0000001",
    "component_name": "腹腔镜下直肠前切除术+回肠预防性单腔造口术",
    "component_status": "source_actual_procedure_component",
    "regimen_definition_id": "REGIMEN_DEFINITION-0000001"
  },
  "patient_regimen_instance": {
    "encounter_id": "ENCOUNTER-0000001",
    "instance_id": "INSTANCE-0000001",
    "instance_status": "source_procedure_instance",
    "patient_id": "PATIENT-0000001",
    "regimen_definition_id": "REGIMEN_DEFINITION-0000001"
  },
  "actual_treatment_event": {
    "actual_end_time": "2026-07-20 11:50:00",
    "actual_start_time": "2026-07-20 09:00:00",
    "actual_status": "actual_source_procedure",
    "instance_id": "INSTANCE-0000001",
    "treatment_event_id": "TREATMENT_EVENT-0000001",
    "treatment_type": "procedure"
  },
  "evaluation_window": [
    {
      "end_time": "2026-07-20 09:00:00",
      "instance_id": "INSTANCE-0000001",
      "regimen_definition_id": "REGIMEN_DEFINITION-0000001",
      "start_time": "2026-07-14T13:46:27",
      "window_id": "WINDOW-0000001",
      "window_semantic": "admission_to_actual_procedure_start",
      "window_type": "preoperative"
    },
    {
      "end_time": "2026-07-29 08:08:16",
      "instance_id": "INSTANCE-0000001",
      "regimen_definition_id": "REGIMEN_DEFINITION-0000001",
      "start_time": "2026-07-20 11:50:00",
      "window_id": "WINDOW-0000002",
      "window_semantic": "actual_procedure_end_to_actual_discharge",
      "window_type": "postoperative_to_discharge"
    }
  ],
  "clinical_outcome": {
    "event_time_raw": "2026-07-29 08:08:16",
    "instance_id": "INSTANCE-0000001",
    "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_state_not_efficacy_or_long_term_outcome"
  },
  "postoperative_source_document": [
    {
      "document_id": "DOCUMENT-0000001",
      "document_title": "术后首次病程记录",
      "event_time_raw": "2026-07-20T15:55:23",
      "instance_id": "INSTANCE-0000001",
      "source_document_key": "SOURCE_DOCUMENT-0000001"
    },
    {
      "document_id": "DOCUMENT-0000002",
      "document_title": "中医治疗协作会诊申请",
      "event_time_raw": "2026-07-21T07:43:17",
      "instance_id": "INSTANCE-0000001",
      "source_document_key": "SOURCE_DOCUMENT-0000002"
    },
    {
      "document_id": "DOCUMENT-0000003",
      "document_title": "医生C职称B查房记录",
      "event_time_raw": "2026-07-21T09:09:50",
      "instance_id": "INSTANCE-0000001",
      "source_document_key": "SOURCE_DOCUMENT-0000003"
    },
    {
      "document_id": "DOCUMENT-0000004",
      "document_title": "中医治疗协作会诊记录",
      "event_time_raw": "2026-07-21T11:57:27",
      "instance_id": "INSTANCE-0000001",
      "source_document_key": "SOURCE_DOCUMENT-0000004"
    },
    {
      "document_id": "DOCUMENT-0000005",
      "document_title": "日常病程记录",
      "event_time_raw": "2026-07-21T17:12:53",
      "instance_id": "INSTANCE-0000001",
      "source_document_key": "SOURCE_DOCUMENT-0000005"
    },
    {
      "document_id": "DOCUMENT-0000006",
      "document_title": "日常病程记录",
      "event_time_raw": "2026-07-22T09:14:20",
      "instance_id": "INSTANCE-0000001",
      "source_document_key": "SOURCE_DOCUMENT-0000006"
    },
    {
      "document_id": "DOCUMENT-0000007",
      "document_title": "日常病程记录",
      "event_time_raw": "2026-07-23T10:38:59",
      "instance_id": "INSTANCE-0000001",
      "source_document_key": "SOURCE_DOCUMENT-0000007"
    },
    {
      "document_id": "DOCUMENT-0000008",
      "document_title": "医生H职称C查房记录",
      "event_time_raw": "2026-07-26T08:53:14",
      "instance_id": "INSTANCE-0000001",
      "source_document_key": "SOURCE_DOCUMENT-0000008"
    },
    {
      "document_id": "DOCUMENT-0000009",
      "document_title": "日常病程记录",
      "event_time_raw": "2026-07-26T16:55:26",
      "instance_id": "INSTANCE-0000001",
      "source_document_key": "SOURCE_DOCUMENT-0000009"
    },
    {
      "document_id": "DOCUMENT-0000010",
      "document_title": "日常病程记录",
      "event_time_raw": "2026-07-29T08:47:55",
      "instance_id": "INSTANCE-0000001",
      "source_document_key": "SOURCE_DOCUMENT-0000010"
    }
  ],
  "quality_issue": {
    "handling": "endpoint/response/long-term and medication administration are zero",
    "instance_id": "INSTANCE-0000001",
    "issue_code": "no_standard_endpoint_baseline_reassessment_actual_medication_or_long_term_followup",
    "quality_issue_id": "QUALITY_ISSUE-0000001"
  }
}