样例字段语义
| 分组 | 字段 | 英文键 | 语义 |
|---|
| 照护病程 | 照护病程 | neurodegenerativecarecourse_id | 一名患者在某一疾病概念与诊断标准版本下的照护病程;换诊断标准即换版本 |
| 诊断断言 | 诊断断言 | diagnosisassertionid | 来源记录中的诊断表述及其确认状态;来源诊断、规则候选与专业确认三层分开,不确定诊断不被上一层覆盖 |
| 认知评估 | 认知评估 | cognitiveassessmentid | 认知功能的量表评估;须有量表名称、版本、语言、总分与完成状态,缺版本与分项时不认定为规范量表结果 |
| 运动评估 | 运动评估 | motorassessmentid | 运动功能的量表评估;与认知、行为属不同评估域,分数不可跨域混算趋势 |
| 行为精神评估 | 行为精神评估 | behavioralassessmentid | 行为与精神症状的评估记录,是照护负担的重要来源 |
| 功能照护基线 | 功能照护基线 | functionalcarebaseline_id | 入院时的日常生活功能与照护需求基线记录 |
| 功能评分来源记录 | 功能评分记录 | functionalscoreid | 自理能力评分及其等级、神志、沟通与活动等来源字段;每条记录是一次入院基线评估 |
| 神经影像评估 | 影像评估 | neurologicimagingassessment_id | 头颅与脑血管影像报告的所见与结论 |
| 照护计划 | 照护计划 | careplanid | 照护建议与护理计划内容;计划、实际干预、复评与效果四者分开,无计划或行动标识时不生成执行关联 |
| 照护者 | 照护者 | caregiver_id | 承担日常照护的角色记录,仅在来源有明确照护者信息时生成 |
| 疾病进展评估 | 进展评估 | progressionassessmentid | 疾病进展的判定记录;须基于同一量表的前后可比结果 |
| 随访任务 | 随访任务 | followuptaskid | 计划中的随访安排与提醒记录 |
| 随访就诊 | 随访就诊 | followupvisitid | 实际发生的随访就诊;计划、联系、实际就诊与量表复测分别记录 |
| 照护结局 | 照护结局 | careoutcomeid | 照护相关的结局事实,观察截止后无记录属观察终止 |
| 覆盖缺口 | 覆盖缺口 | coveragegapid | 观察期内无记录的区间 |
| 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及缺失原因 |
样例记录
神经系统纵向组件与护理功能基线组件并列。前者是跨多年的门诊与住院就诊、头颅与脑血管检查报告及其来源诊断。后者是入院护理功能基线中的自理能力分数与等级、神志、沟通与活动字段。两个组件在缺少可连接键时各自独立呈现。
{
"样例性质": "真实记录·已脱敏",
"neurologic_source_patient": {
"available_time": null,
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"neurologic_source_patient_id": "NEUROLOGIC_SOURCE_PATIENT-0000001",
"parent_object_id": "PARENT_OBJECT-0000001",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000001"
},
"encounter": [
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000001",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000002"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000002",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000003"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000003",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000004"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000004",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000005"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000005",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000006"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000006",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000007"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000007",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000008"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000008",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000009"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000009",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000010"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000010",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000011"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000011",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000012"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000012",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000013"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000013",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000014"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000014",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000015"
},
{
"available_time": null,
"encounter_end_time": null,
"encounter_id": "ENCOUNTER-0000015",
"encounter_start_time": null,
"encounter_type": "source_outpatient_or_inpatient",
"event_time_raw": null,
"missing_reason": "not_covered_or_not_applicable",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000016"
}
],
"functional_care_baseline": [
{
"activity_status": "步行",
"assessment_time": "2022-05-31T11:39:00",
"available_time": null,
"communication": "normal",
"consciousness": "清醒",
"event_time_raw": "2022-05-31T11:39:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000001",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000003",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000001",
"self_care_level": "轻度依赖(总分61-99分)",
"self_care_score": "70",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2022-07-20T17:20:00",
"available_time": null,
"communication": "normal",
"consciousness": "清醒",
"event_time_raw": "2022-07-20T17:20:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000002",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000004",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000002",
"self_care_level": "无需依赖(总分100分)",
"self_care_score": "100",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2021-04-09T14:39:00",
"available_time": null,
"communication": "normal",
"consciousness": "清楚",
"event_time_raw": "2021-04-09T14:39:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000003",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000005",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000003",
"self_care_level": "无需依赖(总分100分)",
"self_care_score": "100",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2021-10-02T15:10:00",
"available_time": null,
"communication": "normal",
"consciousness": "清楚",
"event_time_raw": "2021-10-02T15:10:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000004",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000006",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000004",
"self_care_level": "无需依赖(总分100分)",
"self_care_score": "100",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2022-09-05T14:50:00",
"available_time": null,
"communication": "normal",
"consciousness": "清醒",
"event_time_raw": "2022-09-05T14:50:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000005",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000007",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000005",
"self_care_level": "轻度依赖(总分61-99分)",
"self_care_score": "95",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2021-03-30T10:07:00",
"available_time": null,
"communication": "normal",
"consciousness": "清楚",
"event_time_raw": "2021-03-30T10:07:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000006",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000008",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000006",
"self_care_level": "轻度依赖(总分61-99分)",
"self_care_score": "90",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2021-01-12T10:02:00",
"available_time": null,
"communication": "normal",
"consciousness": "清楚",
"event_time_raw": "2021-01-12T10:02:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000007",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000009",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000007",
"self_care_level": "无需依赖(总分100分)",
"self_care_score": "100",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2022-04-22T11:02:00",
"available_time": null,
"communication": "normal",
"consciousness": "清醒",
"event_time_raw": "2022-04-22T11:02:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000008",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000010",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000008",
"self_care_level": "轻度依赖(总分61-99分)",
"self_care_score": "95",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2022-04-02T15:28:00",
"available_time": null,
"communication": "normal",
"consciousness": "清醒",
"event_time_raw": "2022-04-02T15:28:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000009",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000011",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000009",
"self_care_level": "无需依赖(总分100分)",
"self_care_score": "100",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2022-11-11T12:20:00",
"available_time": null,
"communication": "normal",
"consciousness": "清醒",
"event_time_raw": "2022-11-11T12:20:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000010",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000012",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000010",
"self_care_level": "轻度依赖(总分61-99分)",
"self_care_score": "75",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2022-09-06T15:37:00",
"available_time": null,
"communication": "normal",
"consciousness": "清醒",
"event_time_raw": "2022-09-06T15:37:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000011",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000013",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000011",
"self_care_level": "轻度依赖(总分61-99分)",
"self_care_score": "65",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2022-08-29T11:16:00",
"available_time": null,
"communication": "normal",
"consciousness": "清醒",
"event_time_raw": "2022-08-29T11:16:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000012",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000014",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000012",
"self_care_level": "无需依赖(总分100分)",
"self_care_score": "100",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2021-02-03T10:32:00",
"available_time": null,
"communication": "normal",
"consciousness": "清楚",
"event_time_raw": "2021-02-03T10:32:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000013",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000015",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000013",
"self_care_level": "无需依赖(总分100分)",
"self_care_score": "100",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2022-06-15T15:46:00",
"available_time": null,
"communication": "normal",
"consciousness": "清醒",
"event_time_raw": "2022-06-15T15:46:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000014",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000016",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000014",
"self_care_level": "轻度依赖(总分61-99分)",
"self_care_score": "95",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2022-04-29T09:22:00",
"available_time": null,
"communication": "normal",
"consciousness": "清醒",
"event_time_raw": "2022-04-29T09:22:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000015",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000017",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000015",
"self_care_level": "轻度依赖(总分61-99分)",
"self_care_score": "95",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2021-02-12T15:06:00",
"available_time": null,
"communication": "normal",
"consciousness": "清楚",
"event_time_raw": "2021-02-12T15:06:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000016",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000018",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000016",
"self_care_level": "轻度依赖(总分61-99分)",
"self_care_score": "80",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
"activity_status": "步行",
"assessment_time": "2022-01-15T10:45:00",
"available_time": null,
"communication": "normal",
"consciousness": "清醒",
"event_time_raw": "2022-01-15T10:45:00",
"functional_care_baseline_id": "FUNCTIONAL_CARE_BASELINE-0000017",
"link_status": "unlinked_no_crosswalk",
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000019",
"record_status": "source_record",
"registration_id": "REGISTRATION-0000017",
"self_care_level": "无需依赖(总分100分)",
"self_care_score": "100",
"source_object_id": "SOURCE_OBJECT-0000017",
"tool_name_status": "source_tool_name_missing"
},
{
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],
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"body_part": "头颅",
"component_type": "report_level_not_image_payload",
"encounter_id": "ENCOUNTER-0000001",
"event_time_raw": "2021-06-03 10:16:00",
"exam_time": "2021-06-03 10:16:00",
"findings_raw": "双侧基底节区见点片状低密度影,脑室系统未见受压,中线结构居中,颅内未见出血征象。",
"impression_raw": "双侧基底节区腔隙灶或缺血性白质改变可能;颅内未见急性出血。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "CT",
"neurologic_imaging_assessment_id": "NEUROLOGIC_IMAGING_ASSESSMENT-0000001",
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},
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"event_time_raw": "2021-07-06 11:21:00",
"exam_time": "2021-07-06 11:21:00",
"findings_raw": "双侧基底节区小片低密度影,脑实质内未见急性出血灶,中线结构居中。",
"impression_raw": "双侧基底节区腔隙灶;颅内未见急性出血。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "CT",
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"event_time_raw": "2021-07-07 09:36:00",
"exam_time": "2021-07-07 09:36:00",
"findings_raw": "DWI未见明显弥散受限灶;双侧基底节区及半卵圆中心散在斑点状长T2信号,FLAIR稍高信号。",
"impression_raw": "未见明确新发脑梗死;双侧基底节区腔隙灶及缺血性白质改变。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "MRI_DWI",
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},
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"event_time_raw": "2021-07-08 10:05:00",
"exam_time": "2021-07-08 10:05:00",
"findings_raw": "双侧大脑中动脉、前动脉、后动脉及椎基底动脉血流速度未见明显异常。",
"impression_raw": "颅内主要动脉TCD检测未见明显异常。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "TCD",
"neurologic_imaging_assessment_id": "NEUROLOGIC_IMAGING_ASSESSMENT-0000004",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"report_business_id": "REPORT_BUSINESS-0000004",
"source_object_id": "SOURCE_OBJECT-0000018"
},
{
"available_time": null,
"body_part": "头颅",
"component_type": "report_level_not_image_payload",
"encounter_id": "ENCOUNTER-0000005",
"event_time_raw": "2023-03-01 15:12:00",
"exam_time": "2023-03-01 15:12:00",
"findings_raw": "双侧基底节区腔隙灶同前,脑沟裂稍增宽,颅内未见急性出血或占位征象。",
"impression_raw": "双侧基底节区腔隙灶;未见急性颅内出血。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "CT",
"neurologic_imaging_assessment_id": "NEUROLOGIC_IMAGING_ASSESSMENT-0000005",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"report_business_id": "REPORT_BUSINESS-0000005",
"source_object_id": "SOURCE_OBJECT-0000018"
},
{
"available_time": null,
"body_part": "头颅",
"component_type": "report_level_not_image_payload",
"encounter_id": "ENCOUNTER-0000006",
"event_time_raw": "2024-01-09 10:25:00",
"exam_time": "2024-01-09 10:25:00",
"findings_raw": "双侧基底节区腔隙灶,脑实质内未见急性出血灶,中线结构居中。",
"impression_raw": "颅内未见急性出血;双侧基底节区腔隙灶。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "CT",
"neurologic_imaging_assessment_id": "NEUROLOGIC_IMAGING_ASSESSMENT-0000006",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"report_business_id": "REPORT_BUSINESS-0000006",
"source_object_id": "SOURCE_OBJECT-0000018"
},
{
"available_time": null,
"body_part": "头颅",
"component_type": "report_level_not_image_payload",
"encounter_id": "ENCOUNTER-0000007",
"event_time_raw": "2024-01-10 08:58:00",
"exam_time": "2024-01-10 08:58:00",
"findings_raw": "左侧基底节区及放射冠见点片状DWI高信号、ADC减低,FLAIR稍高信号;脑室系统未见明显受压。",
"impression_raw": "左侧基底节区及放射冠新近脑梗死。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "MRI_DWI",
"neurologic_imaging_assessment_id": "NEUROLOGIC_IMAGING_ASSESSMENT-0000007",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"report_business_id": "REPORT_BUSINESS-0000007",
"source_object_id": "SOURCE_OBJECT-0000018"
},
{
"available_time": null,
"body_part": "头颈部动脉",
"component_type": "report_level_not_image_payload",
"encounter_id": "ENCOUNTER-0000008",
"event_time_raw": "2024-01-10 14:05:00",
"exam_time": "2024-01-10 14:05:00",
"findings_raw": "双侧颈内动脉虹吸段、椎基底动脉壁毛糙并散在钙化斑块,未见责任大血管闭塞。",
"impression_raw": "头颈动脉粥样硬化改变;未见责任大血管闭塞。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "CTA",
"neurologic_imaging_assessment_id": "NEUROLOGIC_IMAGING_ASSESSMENT-0000008",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"report_business_id": "REPORT_BUSINESS-0000008",
"source_object_id": "SOURCE_OBJECT-0000018"
},
{
"available_time": null,
"body_part": "头颅",
"component_type": "report_level_not_image_payload",
"encounter_id": "ENCOUNTER-0000009",
"event_time_raw": "2025-06-13 11:10:00",
"exam_time": "2025-06-13 11:10:00",
"findings_raw": "DWI未见新发弥散受限灶;双侧基底节区、半卵圆中心散在缺血性白质改变,左侧基底节区陈旧性软化灶。",
"impression_raw": "未见明确新发脑梗死;陈旧性脑梗死及缺血性白质改变。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "MRI_DWI",
"neurologic_imaging_assessment_id": "NEUROLOGIC_IMAGING_ASSESSMENT-0000009",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"report_business_id": "REPORT_BUSINESS-0000009",
"source_object_id": "SOURCE_OBJECT-0000018"
},
{
"available_time": null,
"body_part": "头颅",
"component_type": "report_level_not_image_payload",
"encounter_id": "ENCOUNTER-0000010",
"event_time_raw": "2026-07-25 11:06:00",
"exam_time": "2026-07-25 11:06:00",
"findings_raw": "双侧基底节区斑片状低密度影,脑白质密度欠均,颅内未见出血。",
"impression_raw": "双侧基底节区腔隙灶或缺血性白质改变可能;未见急性出血。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "CT",
"neurologic_imaging_assessment_id": "NEUROLOGIC_IMAGING_ASSESSMENT-0000010",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"report_business_id": "REPORT_BUSINESS-0000010",
"source_object_id": "SOURCE_OBJECT-0000018"
},
{
"available_time": null,
"body_part": "头颅",
"component_type": "report_level_not_image_payload",
"encounter_id": "ENCOUNTER-0000011",
"event_time_raw": "2026-07-28 09:28:00",
"exam_time": "2026-07-28 09:28:00",
"findings_raw": "DWI未见明确新发弥散受限灶;双侧基底节区腔隙灶及脑白质少许缺血性改变。",
"impression_raw": "未见明确新发脑梗死;双侧基底节区腔隙灶。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "MRI_DWI",
"neurologic_imaging_assessment_id": "NEUROLOGIC_IMAGING_ASSESSMENT-0000011",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"report_business_id": "REPORT_BUSINESS-0000011",
"source_object_id": "SOURCE_OBJECT-0000018"
},
{
"available_time": null,
"body_part": "头颈部动脉",
"component_type": "report_level_not_image_payload",
"encounter_id": "ENCOUNTER-0000012",
"event_time_raw": "2026-07-28 15:12:00",
"exam_time": "2026-07-28 15:12:00",
"findings_raw": "双侧颈内动脉C4-C7段管壁毛糙,局部轻度狭窄;头颈部多发动脉粥样硬化改变,未见大血管闭塞。",
"impression_raw": "双侧颈内动脉C4-C7段轻度狭窄;头颈部动脉粥样硬化改变。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "CTA",
"neurologic_imaging_assessment_id": "NEUROLOGIC_IMAGING_ASSESSMENT-0000012",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"report_business_id": "REPORT_BUSINESS-0000012",
"source_object_id": "SOURCE_OBJECT-0000018"
},
{
"available_time": null,
"body_part": "脑血管",
"component_type": "report_level_not_image_payload",
"encounter_id": "ENCOUNTER-0000013",
"event_time_raw": "2026-07-29 10:00:00",
"exam_time": "2026-07-29 10:00:00",
"findings_raw": "静息状态及Valsalva动作时未见微栓子信号。",
"impression_raw": "TCD发泡试验阴性。",
"link_status": "within_product_scope",
"missing_reason": null,
"modality": "TCD",
"neurologic_imaging_assessment_id": "NEUROLOGIC_IMAGING_ASSESSMENT-0000013",
"parent_object_id": "PARENT_OBJECT-0000002",
"record_status": "source_record",
"report_business_id": "REPORT_BUSINESS-0000013",
"source_object_id": "SOURCE_OBJECT-0000018"
}
],
"coverage_gap": {
"available_time": null,
"coverage_gap_id": "COVERAGE_GAP-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"
},
"quality_issue": {
"available_time": null,
"event_time_raw": null,
"missing_reason": null,
"parent_object_id": "PARENT_OBJECT-0000001",
"quality_code": "UNLINKED_COMPONENTS",
"quality_issue_id": "QUALITY_ISSUE-0000001",
"quality_message": "no verified cross-source patient or encounter crosswalk",
"record_status": "source_record",
"source_object_id": "SOURCE_OBJECT-0000001"
}
}