住院观察段内的风险评估、并发症与不良事件记录。风险评分停在评估层，事件标签只在有事件证据时生成。并发症与不良事件的定义、来源风险评估明细、出院转归与术后文书一并交付。适用于患者安全建模、护理评估执行核查与上市后安全性监测。
专病与全病程 · 评估与研究使用许可 · 更新日期 2026-08-05
以下内容来自产品说明书，包含数据拓扑、字段字典、脱敏样例、使用场景及定制方式。
| 项 | 数量 | 内容 |
|---|---|---|
| 实体 | 16 | 观察事件段 · 队列定义 · 并发症定义 · 并发症与不良事件 · 事件标签 · 风险窗定义 · 跌倒风险有效评估 · 跌倒风险空分记录 · 管路风险评估候选 · 管路风险来源明细 · 管路风险来源行 · 出院转归 · 术后来源文书 · 对照样本 · 数据质量项 · 来源沿袭 |
| 字段 | 169 | 交付范围内的字段总数 |
| 实体关系 | 3 | 观察事件段 1—n 并发症与不良事件／风险评估／出院转归／术后文书 · 风险评估 1—n 管路风险来源明细；评分与风险等级归属来源评估层 · 事件标签只在有事件证据时生成；不良事件表为空表示该来源未覆盖登记 |
在同一位置切换字段字典、实体血缘与脱敏样例，避免重复铺陈造成页面过长。
| 对象 | 英文键 | 中文名 | 说明 |
|---|---|---|---|
| 队列定义 | cohortdefinitionid | 队列定义标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 队列定义 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 队列定义 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 队列定义 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 队列定义 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 队列定义 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 队列定义 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 队列定义 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 队列定义 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 对照样本 | comparatorsampleid | 对照样本标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 对照样本 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 对照样本 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 对照样本 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 对照样本 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 对照样本 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 对照样本 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 对照样本 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 对照样本 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 并发症定义 | complicationdefinitionid | 并发症定义标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 并发症定义 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 并发症定义 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 并发症定义 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 并发症定义 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 并发症定义 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 并发症定义 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 并发症定义 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 并发症定义 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 并发症与不良事件 | adverseeventid | 不良事件标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 并发症与不良事件 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 并发症与不良事件 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 并发症与不良事件 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 并发症与不良事件 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 并发症与不良事件 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 并发症与不良事件 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 并发症与不良事件 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 并发症与不良事件 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 出院转归 | dischargeoutcomeid | 出院转归标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 出院转归 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 出院转归 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 出院转归 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 出院转归 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 出院转归 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 出院转归 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 出院转归 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 出院转归 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 出院转归 | outcomecontentraw | 结局内容 | 来源原文或原始字段值；保真保留，不因格式化改写为计数、结论或标准编码。 |
| 出院转归 | outcometimeraw | 结局时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 事件标签 | eventlabelid | 事件标签标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 事件标签 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 事件标签 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 事件标签 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 事件标签 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 事件标签 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 事件标签 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 事件标签 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 事件标签 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 跌倒风险空分记录 | fallriskempty_id | 跌倒风险空分标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 跌倒风险空分记录 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 跌倒风险空分记录 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 跌倒风险空分记录 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 跌倒风险空分记录 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 跌倒风险空分记录 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 跌倒风险空分记录 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 跌倒风险空分记录 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 跌倒风险空分记录 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 跌倒风险空分记录 | score_value | 评分值 | 数值测量、剂量、分值或金额；单位、参考范围和换算规则以同表字段为准。 |
| 跌倒风险空分记录 | risklevelraw | 风险等级 | 来源原文或原始字段值；保真保留，不因格式化改写为计数、结论或标准编码。 |
| 跌倒风险空分记录 | assessmenttimeraw | 评估时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 跌倒风险空分记录 | assessment_slot | 评估槽位 | 与该表业务对象直接相关的文本属性。 |
| 跌倒风险有效评估 | fallriskassessment_id | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 | |
| 跌倒风险有效评估 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 跌倒风险有效评估 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 跌倒风险有效评估 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 跌倒风险有效评估 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 跌倒风险有效评估 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 跌倒风险有效评估 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 跌倒风险有效评估 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 跌倒风险有效评估 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 跌倒风险有效评估 | score_value | 评分值 | 数值测量、剂量、分值或金额；单位、参考范围和换算规则以同表字段为准。 |
| 跌倒风险有效评估 | risklevelraw | 风险等级 | 来源原文或原始字段值；保真保留，不因格式化改写为计数、结论或标准编码。 |
| 跌倒风险有效评估 | assessmenttimeraw | 评估时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 跌倒风险有效评估 | assessment_slot | 评估槽位 | 与该表业务对象直接相关的文本属性。 |
| 观测轨迹 | observationepisodeid | 观测轨迹标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 观测轨迹 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 观测轨迹 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 观测轨迹 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 观测轨迹 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 观测轨迹 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 观测轨迹 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 观测轨迹 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 观测轨迹 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 术后来源文书 | postoperativedocumentid | 术后文书标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 术后来源文书 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 术后来源文书 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 术后来源文书 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 术后来源文书 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 术后来源文书 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 术后来源文书 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 术后来源文书 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 术后来源文书 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 术后来源文书 | documentcontentraw | 文书正文 | 来源原文或原始字段值；保真保留，不因格式化改写为计数、结论或标准编码。 |
| 术后来源文书 | documenttimeraw | 文书时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 数据质量项 | qualityissueid | 数据质量项标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 数据质量项 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 数据质量项 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 数据质量项 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 数据质量项 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 数据质量项 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 数据质量项 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 数据质量项 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 数据质量项 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 风险窗定义 | riskwindowdefinition_id | 风险窗定义标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 风险窗定义 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 风险窗定义 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 风险窗定义 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 风险窗定义 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 风险窗定义 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 风险窗定义 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 风险窗定义 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 风险窗定义 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 来源沿袭 | lineage_id | 沿袭标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 来源沿袭 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 来源沿袭 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 来源沿袭 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 来源沿袭 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 来源沿袭 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 来源沿袭 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 来源沿袭 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 来源沿袭 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 来源沿袭 | object_type | 对象类型 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 来源沿袭 | object_id | 对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 来源沿袭 | source_locator | 来源定位 | 与该表业务对象直接相关的文本属性。 |
| 来源沿袭 | transformation_rule | 转换规则 | 与该表业务对象直接相关的文本属性。 |
| 管路风险评估候选 | tuberiskcandidate_id | 管路风险候选标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 管路风险评估候选 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 管路风险评估候选 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 管路风险评估候选 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 管路风险评估候选 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 管路风险评估候选 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 管路风险评估候选 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 管路风险评估候选 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 管路风险评估候选 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 管路风险评估候选 | score_value | 评分值 | 数值测量、剂量、分值或金额；单位、参考范围和换算规则以同表字段为准。 |
| 管路风险评估候选 | risklevelraw | 风险等级 | 来源原文或原始字段值；保真保留，不因格式化改写为计数、结论或标准编码。 |
| 管路风险评估候选 | assessmenttimeraw | 评估时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 管路风险来源明细 | tuberiskdetail_id | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 | |
| 管路风险来源明细 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 管路风险来源明细 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 管路风险来源明细 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 管路风险来源明细 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 管路风险来源明细 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 管路风险来源明细 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 管路风险来源明细 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 管路风险来源明细 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 管路风险来源明细 | tubeitemname | 管路项目名称 | 与该表业务对象直接相关的文本属性。 |
| 管路风险来源明细 | tubeitemvalue | 管路项目取值 | 数值测量、剂量、分值或金额；单位、参考范围和换算规则以同表字段为准。 |
| 管路风险来源明细 | assessmenttimeraw | 评估时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 管路风险来源行 | tuberisksourcerowid | 管路风险来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 管路风险来源行 | parentobjectid | 父对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 管路风险来源行 | record_status | 记录状态 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 管路风险来源行 | sourceobjectid | 来源对象标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 管路风险来源行 | sourcerowid | 来源行标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 管路风险来源行 | eventtimeraw | 事件时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 管路风险来源行 | available_time | 可用时间 | 来源或业务时间；仅按该字段声明的语义参与排序，缺失时保持空值。 |
| 管路风险来源行 | missing_reason | 缺失原因 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 管路风险来源行 | data_nature | 数据性质 | 受控状态或范围枚举；用于表达来源性质、覆盖、映射或处理边界。 |
| 管路风险来源行 | tubetyperaw | 管路类型 | 来源原文或原始字段值；保真保留，不因格式化改写为计数、结论或标准编码。 |
| 管路风险来源行 | tubevalueraw | 管路取值 | 来源原文或原始字段值；保真保留，不因格式化改写为计数、结论或标准编码。 |
| 管路风险来源行 | risklevelraw | 风险等级 | 来源原文或原始字段值；保真保留，不因格式化改写为计数、结论或标准编码。 |
数据血缘拓扑
实体与连接关系分层呈现：上方先识别全部数据对象，下方逐条阅读关系基数，避免连线交叠、标签遮挡或内容被裁切。
范围 · 父对象
判定口径 · 版本
归因时间窗
事件记录
建模用标签
评分 · 等级 · 时段
有评估无评分
评分 · 等级
管路类型与状态
逐项内容与取值
转归内容与时间
正文 · 记录时间
观察对象范围
比较集合
quality_issue
source_lineage
每条关系独占一行，基数置于两实体之间
队列定义
观察对象范围
观察事件段
范围 · 父对象
观察事件段
范围 · 父对象
并发症与不良事件
事件记录
并发症定义
判定口径 · 版本
并发症与不良事件
事件记录
风险窗定义
归因时间窗
并发症与不良事件
事件记录
并发症与不良事件
事件记录
事件标签
建模用标签
观察事件段
范围 · 父对象
跌倒风险有效评估
评分 · 等级 · 时段
观察事件段
范围 · 父对象
跌倒风险空分记录
有评估无评分
观察事件段
范围 · 父对象
管路风险评估候选
评分 · 等级
管路风险评估候选
评分 · 等级
管路风险来源明细
逐项内容与取值
管路风险来源行
管路类型与状态
管路风险评估候选
评分 · 等级
观察事件段
范围 · 父对象
出院转归
转归内容与时间
观察事件段
范围 · 父对象
术后来源文书
正文 · 记录时间
队列定义
观察对象范围
对照样本
比较集合
| 起 | 基数 | 至 | 关系语义 |
|---|---|---|---|
| 队列定义 | 1—n | 观察事件段 | 队列定义下的观察事件段 |
| 观察事件段 | 1—n | 并发症与不良事件 | 事件段内登记的并发症与不良事件 |
| 并发症定义 | 1—n | 并发症与不良事件 | 事件按并发症定义判定 |
| 风险窗定义 | 1—n | 并发症与不良事件 | 事件是否归因于本次治疗由风险窗判定 |
| 并发症与不良事件 | 1—n | 事件标签 | 有事件证据才生成建模标签 |
| 观察事件段 | 1—n | 跌倒风险有效评估 | 事件段内的跌倒风险评估 |
| 观察事件段 | 1—n | 跌倒风险空分记录 | 评分缺失的评估单列 |
| 观察事件段 | 1—n | 管路风险评估候选 | 事件段内的管路风险评估 |
| 管路风险评估候选 | 1—n | 管路风险来源明细 | 评估下逐项管路明细 |
| 管路风险来源行 | 1—n | 管路风险评估候选 | 来源行构成评估候选 |
| 观察事件段 | 1—n | 出院转归 | 事件段的出院转归 |
| 观察事件段 | 1—n | 术后来源文书 | 事件段内的术后文书 |
| 队列定义 | 1—n | 对照样本 | 与事件定义配套声明的对照样本 |
风险评估、实际事件、事件标签分三层保存。评估层记评分与等级，事件层记实际发生的事，标签层记供建模使用的事件标签。
| 分组 | 字段 | 英文键 | 语义 |
|---|---|---|---|
| 观察事件段 | 事件段标识与父对象 | observationepisodeid / parentobjectid | 本次观察的范围及其所属住院或病程，全部评估与事件挂在这一层下 |
| 并发症定义 | 并发症定义 | complicationdefinitionid | 本次数据采用的并发症判定口径；换口径即换定义版本，事件计数随之重算 |
| 风险窗定义 | 风险窗定义 | riskwindowdefinition_id | 判定某事件是否属于本次治疗相关并发症所用的时间窗，窗口写在数据里 |
| 并发症与不良事件 | 记录状态 | record_status | 该事件记录的状态；来源未开展不良事件登记时本表为空并在质量项中说明覆盖不可得 |
| 事件标签 | 事件标签 | eventlabelid | 供建模使用的事件标签，仅在有明确事件证据时生成 |
| 跌倒风险有效评估 | 评分取值与风险等级 | scorevalue / risklevel_raw | 护理跌倒风险量表的得分与判定等级 |
| 跌倒风险有效评估 | 评估时间与评估时段 | assessmenttimeraw / assessment_slot | 该次评估的时点及其所属班次或时段，同一日多次评估据此区分 |
| 跌倒风险空分记录 | 空分记录 | fallriskempty_id | 有评估动作但评分缺失的记录，单列保存并保持缺失 |
| 管路风险评估候选 | 评分与等级 | scorevalue / risklevel_raw | 管路相关风险的评估得分与等级 |
| 管路风险来源明细 | 管路项目名与取值 | tubeitemname / tubeitemvalue | 评估中逐项记录的管路检查内容与结果，是评分的构成依据 |
| 管路风险来源行 | 管路类型与取值 | tubetyperaw / tubevalueraw | 该患者留置的管路类型与状态记录 |
| 出院转归 | 转归内容与时间 | outcomecontentraw / outcometimeraw | 出院时对病情转归的记录及其时点 |
| 术后来源文书 | 文书内容与时间 | documentcontentraw / documenttimeraw | 术后病程与查房文书正文及记录时点，是识别并发症线索的原始文本 |
| 对照样本 | 对照样本 | comparatorsampleid | 用于比较的对照集合，随事件定义与风险窗一同声明 |
| 全表 | 首次可用时间与缺失原因 | availabletime / missingreason | 该记录首次可被读取的时点；缺失时记明原因，据此判断能否用于事件发生前的预测 |
一段住院观察内的护理风险评估记录。跌倒风险有评分、等级与评估时段，管路风险按管路逐项记录来源明细。术后文书与出院转归一并呈现。评分为空的评估单独成条，不按低风险处理。
{
"样例性质": "真实记录·已脱敏",
"observation_episode": {
"available_time": null,
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"observation_episode_id": "OBSERVATION_EPISODE-0000001",
"parent_object_id": "PARENT_OBJECT-0000001",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000001"
},
"cohort_definition": {
"available_time": null,
"cohort_definition_id": "COHORT_DEFINITION-0000001",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000001",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000001"
},
"complication_definition": {
"available_time": null,
"complication_definition_id": "COMPLICATION_DEFINITION-0000001",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000001",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000001"
},
"risk_window_definition": {
"available_time": null,
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000001",
"record_status": "source_record",
"risk_window_definition_id": "RISK_WINDOW_DEFINITION-0000001",
"source_object_id": "SOURCE_OBJECT-0000001"
},
"postoperative_source_document": [
{
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"document_content_raw": "2026-07-24 16:54 首次病程记录\n患者A，女，80岁，无业人员，因“便血1天”于2026-07-24入院。\n一、病史特点：\n1.患者老年女性，起病急、病程短。\n2.以“便血1天”为主要临床表现入院。\n3.既往史：既往既往一般，患高血压20+年，最高达150/？mmHg，目前服用降压药替米沙坦片，，否认心脏病史,否认糖尿病,否认哮喘,20+年前脑梗死，口服阿司匹林肠溶片,否认精神疾病史,否认肝炎，否认结核，否认疟疾，白内障手术，否认外伤史，否认输血史。\n4.查体：体温36.5℃、脉搏64次/分、呼吸20次/分、血压130/78mmHg，生命体征平稳，心肺腹未见明显阳性体征。专科检查：肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。\n5.辅助检查：-\n二、初步诊断：直肠肿物 高血压\n三、诊断依据：\n1.直肠肿物，诊断依据：患者因“便血1天”入院。专科检查：肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂；\n2.高血压，诊断依据：结合既往史诊断。\n四、鉴别诊断：\n内痔：内痔早期以出血为主要表现，颜色多鲜红，不伴肛门疼痛，可伴有肛门内肿物脱出，肛门镜下可见齿线处粘膜充盈明显，部分齿线消失。内痔痔核为曲张静脉丛，呈桑葚状或结节状突起，颜色紫暗或鲜红。各痔核间常有明显界线或正常的粘膜组织。\n五、入院病情评估：患者生命体征平稳，意识清楚，自主能力正常，告知患者及家属可能疾病诊断、疾病诊疗方法、风险及转归可能，需要24h留陪。入院VTE评分3分，出血风险低危，暂无特殊处理，嘱患者尽早活动。\n六、诊疗计划：1、肛肠科护理常规、二级护理、低盐饮食；2、完善血常规、凝血功能、生化检查、感染性标志物、大小便常规、心电图、心脏彩超、颈部血管彩超等；3、完善肠镜检查。\n医师签名：医生I\n",
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"document_content_raw": "2026-07-25 08:08 医生I职称B首次查房记录\n 今医生I职称B查看病人及总结病史特点如下：患者老年女性，起病急、病程短。“便血1天”入院。既往史：既往一般，患高血压20+年，最高达150/？mmHg，目前服用降压药替米沙坦片，否认心脏病史,否认糖尿病,否认哮喘,20+年前脑梗死，口服阿司匹林肠溶片,否认精神疾病史,否认肝炎，否认结核，否认疟疾，白内障手术。查体:肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。辅助检查 :2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增、室间隔基底段增厚、主动脉瓣轻度反流、2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。目前诊断:直肠肿物，高血压。诊断依据：1.直肠肿物，诊断依据：患者因“便血1天”入院。专科检查：肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂；2.高血压，诊断依据：结合既往史诊断。鉴别诊断:内痔：内痔早期以出血为主要表现，颜色多鲜红，不伴肛门疼痛，可伴有肛门内肿物脱出，肛门镜下可见齿线处粘膜充盈明显，部分齿线消失。内痔痔核为曲张静脉丛，呈桑葚状或结节状突起，颜色紫暗或鲜红。各痔核间常有明显界线或正常的粘膜组织。查房指示： 1、完善结肠镜检查等。2、明确手术禁忌，积极术前准备，择期行手术治疗。3、术后养成良好饮食排便习惯。4、注意讲明白手术方案及风险。\n医师签名:医生I\n",
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"document_content_raw": "2026-07-26 12:06 医生P职称C首次查房记录\n 医生P职称C查房，患者老年女性，起病急、病程短。“便血1天”入院。既往史：既往一般，患高血压20+年，最高达150/？mmHg，目前服用降压药替米沙坦片，否认心脏病史,否认糖尿病,否认哮喘,20+年前脑梗死，口服阿司匹林肠溶片,白内障手术。查体:肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。辅助检查:2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）,1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌。目前诊断: 直肠肿物 高血压。诊断依据：1.直肠恶性肿瘤，诊断依据：患者因“便血1天”入院。专科检查：肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂；2.高血压，诊断依据：结合既往史诊断。鉴别诊断:内痔：内痔早期以出血为主要表现，颜色多鲜红，不伴肛门疼痛，可伴有肛门内肿物脱出，肛门镜下可见齿线处粘膜充盈明显，部分齿线消失。内痔痔核为曲张静脉丛，呈桑葚状或结节状突起，颜色紫暗或鲜红。各痔核间常有明显界线或正常的粘膜组织。诊疗计划:1、告知患者家属病情；2.患者家属要求转科治疗。\n医师签名：医生P/医生I\n",
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"document_content_raw": "2026-07-27 09:12 转出记录\n患者A，女，80岁，因便血1天于2026-07-24入院。\n入院科室：肛肠科，转出日期：2026-07-27 08:13。转入科室：胃肠外科一病区，已住院3天。\n入院情况：患者A，女，80岁，无业人员，因“便血1天”于2026-07-24入院。专科检查：肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。\n入院诊断：直肠肿物，高血压。\n诊疗经过：入院后完善相关检查，2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增、室间隔基底段增厚、主动脉瓣轻度反流、2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）。1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌；患者家属商量后，要求转入胃肠外科一病区进一步治疗。\n目前情况：患者一般情况可。\n转出诊断：直肠恶性肿瘤，高血压，头臂干分叉处斑块。\n转科目的：进一步治疗。\n注意事项：遵贵科。\n医师签名：医生I\n\n",
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"document_content_raw": "2026-07-27 10:40 转入记录\n患者A，女，80岁，因“便血1天”于2026-07-24入院。\n入院科室：肛肠科，转入日期：2026-07-27 09:41。转入科室：胃肠外科一病区 已住院3天\n入院情况：患者A，女，80岁，因“便血1天”于2026-07-24入院。专科检查：肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。\n入院诊断：直肠肿物，高血压。\n诊疗经过：入院后完善相关检查，2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增、室间隔基底段增厚、主动脉瓣轻度反流、2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）,1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌；患者家属商量后，要求转入胃肠外科一病区进一步治疗。\n目前情况：患者一般情况可。\n转入诊断：直肠恶性肿瘤，高血压，头臂干分叉处斑块。\n诊疗计划：完善术前检查，给与对症治疗，限期手术治疗。\n医师签名：医生C\n",
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"document_content_raw": "2026-07-28 15:08 医生C职称B查房记录(首次)\n 今医生C职称B查看病人及总结病史特点如下：患者A，女，80岁，因“便血1天”于2026-07-24入院。查体:肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。辅助检查 :2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增、室间隔基底段增厚、主动脉瓣轻度反流、2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）,1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌。目前诊断: 直肠恶性肿瘤，高血压，头臂干分叉处斑块。诊断依据：结合患者主诉、查体及辅助检查可诊断。鉴别诊断:1.内痔：内痔早期以出血为主要表现，颜色多鲜红，不伴肛门疼痛，可伴有肛门内肿物脱出，肛门镜下可见齿线处粘膜充盈明显，部分齿线消失。内痔痔核为曲张静脉丛，呈桑葚状或结节状突起，颜色紫暗或鲜红。各痔核间常有明显界线或正常的粘膜组织。2.直肠息肉：此病可有大便不适，也可以是便血，有些患者还伴有脓血便，目前结肠镜及活检结果不支持。3.溃疡性结直肠炎：本病以腹泻、黏液便、脓血便、大便次数增多、腹胀、腹痛等为主要症状，目前肠镜结果不支持。查房指示：完善术前检查，给与对症治疗，限期手术治疗。\n医师签名:医生C\n",
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"document_content_raw": "2026-07-29 09:10 医生H职称C查房记录(首次)\n 医生H职称C查房：老年女性，因“便血1天”于2026-07-24入院。查体:肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。辅助检查:2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增、室间隔基底段增厚、主动脉瓣轻度反流、2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）。1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌。目前诊断: 直肠恶性肿瘤，高血压，头臂干分叉处斑块。诊断依据：结合患者主诉、查体及辅助检查可诊断。鉴别诊断:1.内痔：内痔早期以出血为主要表现，颜色多鲜红，不伴肛门疼痛，可伴有肛门内肿物脱出，肛门镜下可见齿线处粘膜充盈明显，部分齿线消失。内痔痔核为曲张静脉丛，呈桑葚状或结节状突起，颜色紫暗或鲜红。各痔核间常有明显界线或正常的粘膜组织。2.直肠息肉：此病可有大便不适，也可以是便血，有些患者还伴有脓血便，目前结肠镜及活检结果不支持。3.溃疡性结直肠炎：本病以腹泻、黏液便、脓血便、大便次数增多、腹胀、腹痛等为主要症状，目前肠镜结果不支持。诊疗计划:目前治疗方案：1、保守治疗：可选择行放化疗等保守治疗，但可能患者对保守治疗效果差，肿瘤继续出血、梗阻，耽误手术时机等。2、手术治疗：解决肿瘤引起的出血、梗阻等症状，切除肿瘤后延迟生命，但需要承担手术风险，术后根据病检结果决定是否进一步行放化疗。与患者及其家属充分沟通，交代治疗方式及风险。继续完善入院术前相关检查，等待检查结果。患者诉轻微排便不适，给予对症治疗，指导患者加强肺功能锻炼。\n医师签名：医生H/医生C\n",
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"document_content_raw": "2026-07-29 15:13 日常病程记录\n 今日查看患者，精神、饮食、睡眠可，轻微排便不适，无咳嗽咳痰，无畏寒发热，无胸闷气喘心悸等特殊不适，小便可。查体情况：心脏未见明显异常，双肺呼吸音粗，未闻及明显干湿啰音，腹软，未见肠型及蠕动波，全腹无明显压痛、反跳痛及肌紧张，肝脾未及肿大，未触及包块，双肾区无叩痛，移动性浊音阴性，肠鸣4-5次/分。辅助检查情况：2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增大；室间隔基底段增厚；主动脉瓣轻度反流。2026-07-25 无感觉电子结肠直肠镜检查,直肠LST（中央隆起区域性质？）；直肠息肉；内镜色素NBI、靛胭脂染色检查术。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌。2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）。1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-27 常规心电图+十二通道加收,1.窦性心律；2.T波改变。2026-07-28 上腹部MR平扫+DWI+胰胆管薄层扫描成像（MRCP),直肠MR平扫+DWI+增强高分辨薄层扫描,MR平扫特殊方式成像,MR增强特殊方式成像。1、胆囊多发结石伴胆囊炎。2、胆总管内多发小结石，肝内外胆管稍扩张。3、肝实质、胰腺、脾脏平扫未见确切异常，必要时增强检查。4、扫及：双肾囊肿、右肾盂旁囊肿可能。5、直肠下段Ca（mrT2N0M0），直肠系膜筋膜MRF（-），直肠壁外血管侵犯EMVI（-）。2026-07-28 胸部CT薄层平扫+薄层增强+能量成像,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）,1、双肺散在纤维灶，胸膜下坠积效应，较前相似。2、右肺下叶背段小结节，LU-RADS 2类，较前部分结节此次未见显示。3、冠状动脉及主动脉钙化。4、双侧胸膜稍增厚。5、扫及胆囊结石可能；甲状腺右侧叶低密度结节，请结合超声检查。诊疗计划：给予对症治疗，指导肺部功能锻炼。\n医师签名：医生C\n",
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"document_content_raw": "2026-07-29 16:35 术前讨论记录\n讨论日期：2026-07-29 16:00 讨论地点：外科办公室\n主持人：医生L 病区主任\n参加讨论人员：职称A：医生L；职称C：医生AN、医生H；职称B：医生C、医生AO、医生AP；所有规范化培训医师、实习及进修医师。\n病史汇报：职称B查看病人及总结病史特点如下：患者A，女，80岁，因“便血1天”于2026-07-24入院。查体:肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。辅助检查 :2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增大；室间隔基底段增厚；主动脉瓣轻度反流。2026-07-25 无感觉电子结肠直肠镜检查,直肠LST（中央隆起区域性质？）；直肠息肉；内镜色素NBI、靛胭脂染色检查术。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌。2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）,1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-27 常规心电图+十二通道加收,1.窦性心律；2.T波改变。2026-07-28 上腹部MR平扫+DWI+胰胆管薄层扫描成像（MRCP),直肠MR平扫+DWI+增强高分辨薄层扫描,MR平扫特殊方式成像,MR增强特殊方式成像,1、胆囊多发结石伴胆囊炎。2、胆总管内多发小结石，肝内外胆管稍扩张。3、肝实质、胰腺、脾脏平扫未见确切异常，必要时增强检查。4、扫及：双肾囊肿、右肾盂旁囊肿可能。5、直肠下段Ca（mrT2N0M0），直肠系膜筋膜MRF（-），直肠壁外血管侵犯EMVI（-）。2026-07-28 胸部CT薄层平扫+薄层增强+能量成像,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）,1、双肺散在纤维灶，胸膜下坠积效应，较前相似。2、右肺下叶背段小结节，LU-RADS 2类，较前部分结节此次未见显示。3、冠状动脉及主动脉钙化。4、双侧胸膜稍增厚。5、扫及胆囊结石可能；甲状腺右侧叶低密度结节，请结合超声检查。2026-07-24 血常规:大型血小板比率 50.3(%)↑，平均血小板体积 13.6(fL)↑；2026-07-24 凝血功能:活化部分凝血活酶时间 23.3(sec)↓；2026-07-24 生化全套:总蛋白 60.4(g/L)↓，白蛋白 39.5(g/L)↓，总胆红素 22.4(umol/L)↑，直接胆红素 4.9(umol/L)↑，间接胆红素 17.5(umol/L)↑。\n术前诊断：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。\n讨论意见：管床规培医师汇报病史：患者病史如上。医生C职称B：目前直肠癌诊断明确，目前治疗方案：1、保守治疗：可选择行新辅助放化疗等保守治疗，但可能患者对保守治疗效果差，肿瘤继续出血、梗阻，耽误手术时机等。2、手术治疗：解决肿瘤引起的出血、梗阻等症状，切除肿瘤后延迟生命，但需要承担手术风险，术后根据病检结果决定是否进一步行放化疗。与患者及其家属充分沟通，交代治疗方式及风险。医生H职称C：患者目前诊断明确：直肠癌，有手术指征，无绝对手术禁忌症。手术为全麻下腹腔镜直肠癌根治术，使用全身麻醉，患者取截石位。入腹后先探查腹膜、肝脏、胃、小肠、大网膜及盆腔等处是否有转移病灶，然后游离直肠及乙状结肠系膜，根据有无远处转移、粘连情况、肿瘤大小、位置等因素决定具体手术方式、切除范围。术中注意操作轻柔，止血牢固，防止损伤骶前静脉丛、输尿管、大血管、神经、膀胱等。术后加强支持治疗。\n手术主刀医生L：拟定主要术式：腹腔镜下直肠根治术, 患者目前诊断明确：直肠癌，为有手术指征，同意手术。各项术前检查未发现明显手术禁忌症。手术方式同意行腹腔镜直肠癌根治术。入腹后常规探查，手术方式需根据术中探查结果决定：根治术；姑息性切除；造瘘；无法切除；其他。若肿瘤大，患者身体情况差，直肠癌位置低，可术中行末端回肠预防性造瘘，如若探查发现患者已失去根治性手术机会，则行结肠造瘘术。术前向患者及其家属说明可能行人工肛门及术后的影响等。术中注意操作轻，止血牢。术中采用直肠全系膜切除术（TME）以期达良好预后情况，注意游离骶前间隙时防止损伤骶前静脉丛，游离直肠时注意保护输尿管，并防止输尿管损伤。术后注意防止肝肾心肺并发症，注意补液。",
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医疗科技企业 · 患者安全与不良事件预警产品团队
获得：标签来源清楚、缺失如实标注的患者安全建模底表
三甲医院 · 护理部与医疗质量管理
获得：评估执行与事件登记的差距可量化、可定位
药械企业 · 上市后安全性监测
获得：归因口径明确、有对照分母的安全性观察数据
医疗大模型团队 · 事件识别
获得：事件识别有真实文书与登记参照，措辞不越过证据
并发症与不良事件数据包含什么？
并发症与不良结局数据（SHP-MED-02-011）含住院观察段内的风险评估、并发症与不良事件记录，另有并发症定义、风险窗定义、出院转归与术后文书。字段有评分取值与风险等级、评估时间与时段、管路类型与逐项取值、事件时间与首次可用时间。
患者安全预警模型的特征和标签怎么分？
并发症与不良结局数据（SHP-MED-02-011）把风险量表得分与事件记录分层保存，前者取作特征、后者取作标签，两者来源清楚。护理部可核查评估执行率与评分明细一致性，药械企业可按声明的风险窗做上市后安全性观察与归因边界设定。
不良结局数据怎么交付？
并发症与不良结局数据（SHP-MED-02-011）的产品页给出真实脱敏样例与逐字段语义说明。交付形态有数据集（事件段与评估表、事件与转归表、定义与窗口表）、API 调用、Token 计量与可信数据空间连接器合约使用，数据量按项目商定。
能按跌倒或管路风险单独定制吗？
并发症与不良结局数据（SHP-MED-02-011）可按并发症定义清单或护理不良事件类别划定口径，并可按病种、风险评估类型（跌倒、管路、压力性损伤等）、风险窗长度与指定科室定制，起订量为 5,000 个观察事件段。可先申请开源子集或测试数据起步。
患者安全研究还要配哪些数据集？
并发症与不良结局数据（SHP-MED-02-011）与护理评估—干预—复评数据（SHP-MED-04-029）组合，可接上评估之后的干预与复评闭环；与术后并发症与恢复数据（SHP-MED-04-027）组合，可展开术后阶段的并发症与恢复明细。
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按产品资料中登记的患者、就诊、事件或任务标识关系继续查看。