样例字段语义
| 分组 | 字段 | 英文键 | 语义 |
|---|
| 术后片段 | 术后片段标识 | episode_id | 一次实际手术之后的恢复片段主键,与手术操作一一对应 |
| 术后片段 | 起算时点 | index_time | 术后计时的零点,取手术结束时点 |
| 术后片段 | 术后日计算规则版本 | podruleversion | 相对术后日的计算规则及其版本;跨项目比较前须核对为同一版本 |
| 术后片段 | 手术操作标识 | procedure_id | 该恢复片段所对应的那台手术;同一住院多台手术不共用片段 |
| 观察窗 | 观察窗开始时间 | start_time | 术后观察的起点 |
| 观察窗 | 观察窗结束时间 | end_time | 术后观察的止点 |
| 观察窗 | 覆盖状态 | coverage_status | 观察实际覆盖到哪一段;本例覆盖至出院前 |
| 术后文书 | 文书类型 | document_type | 术后首次病程记录、查房记录、会诊申请与记录、出院记录等文书类别 |
| 术后文书 | 文书时间 | document_time | 该份文书的记录时点,与其中所述临床事件的发生时间分列 |
| 恢复观察 | 观测标识 | observation_id | 自一份术后文书中析出的一条恢复事实 |
| 恢复观察 | 陈述状态 | assertion_status | 该条事实在来源中的性质;本例为来源直接写明的非并发症陈述 |
| 恢复观察 | 相对术后日 | relative_pod | 该条事实对应的术后第几日,区分来源直接写明与按起算点推算两种取得方式 |
| 恢复观察 | 所属文书 | document_id | 该条事实所出自的文书,供逐条回溯到来源段落 |
| 并发症事件 | 并发症定义版本 | definition_version | 判定该并发症所依据的定义及其版本;无约定定义时不生成事件 |
| 并发症事件 | 严重度分级 | severity_grade | 按所声明的严重度体系给出的等级 |
| 临床结局 | 结局类型 | outcome_type | 出院、再手术、再入院、死亡等结局类别 |
| 临床结局 | 随访覆盖状态 | coverage_status | 出院之后的随访覆盖范围;未覆盖记为未知,不写作「无事件」 |
| 数据质量项 | 处理方式 | handling | 该问题在数据集中的处理口径,随数据一同交付 |
样例记录
一次直肠癌手术后至出院的恢复过程数据,以手术结束时点为起算点。含出院前观察窗及其覆盖状态。术后文书共十份,自术后首次病程记录至日常病程记录,各带时间。逐份文书对应的恢复观察带陈述状态与相对术后日。另有出院结局及其随访覆盖状态。
{
"样例性质": "真实记录·已脱敏",
"postoperative_episode": {
"episode_id": "EPISODE-0000001",
"index_time": "2026-07-20 11:50:00",
"patient_token": "PATIENT-0000001",
"pod_rule_version": "natural_day_v1",
"procedure_id": "PROCEDURE-0000001"
},
"observation_period": {
"coverage_status": "discharge_pre_only",
"end_time": "2026-07-29 08:08:16",
"episode_id": "EPISODE-0000001",
"period_id": "PERIOD-0000001",
"start_time": "2026-07-20 11:50:00"
},
"postoperative_document": [
{
"document_id": "DOCUMENT-0000001",
"document_time": "2026-07-20T15:55:23",
"document_type": "术后首次病程记录",
"episode_id": "EPISODE-0000001"
},
{
"document_id": "DOCUMENT-0000002",
"document_time": "2026-07-21T07:43:17",
"document_type": "日常病程记录",
"episode_id": "EPISODE-0000001"
},
{
"document_id": "DOCUMENT-0000003",
"document_time": "2026-07-21T09:09:50",
"document_type": "其他日常查房记录",
"episode_id": "EPISODE-0000001"
},
{
"document_id": "DOCUMENT-0000004",
"document_time": "2026-07-21T11:57:27",
"document_type": "日常病程记录",
"episode_id": "EPISODE-0000001"
},
{
"document_id": "DOCUMENT-0000005",
"document_time": "2026-07-21T17:12:53",
"document_type": "日常病程记录",
"episode_id": "EPISODE-0000001"
},
{
"document_id": "DOCUMENT-0000006",
"document_time": "2026-07-22T09:14:20",
"document_type": "日常病程记录",
"episode_id": "EPISODE-0000001"
},
{
"document_id": "DOCUMENT-0000007",
"document_time": "2026-07-23T10:38:59",
"document_type": "日常病程记录",
"episode_id": "EPISODE-0000001"
},
{
"document_id": "DOCUMENT-0000008",
"document_time": "2026-07-26T08:53:14",
"document_type": "其他日常查房记录",
"episode_id": "EPISODE-0000001"
},
{
"document_id": "DOCUMENT-0000009",
"document_time": "2026-07-26T16:55:26",
"document_type": "日常病程记录",
"episode_id": "EPISODE-0000001"
},
{
"document_id": "DOCUMENT-0000010",
"document_time": "2026-07-29T08:47:55",
"document_type": "日常病程记录",
"episode_id": "EPISODE-0000001"
}
],
"recovery_observation": [
{
"assertion_status": "source_asserted_not_complication",
"document_id": "DOCUMENT-0000001",
"episode_id": "EPISODE-0000001",
"observation_id": "OBSERVATION-0000001",
"relative_pod": "source_or_derived"
},
{
"assertion_status": "source_asserted_not_complication",
"document_id": "DOCUMENT-0000002",
"episode_id": "EPISODE-0000001",
"observation_id": "OBSERVATION-0000002",
"relative_pod": "source_or_derived"
},
{
"assertion_status": "source_asserted_not_complication",
"document_id": "DOCUMENT-0000003",
"episode_id": "EPISODE-0000001",
"observation_id": "OBSERVATION-0000003",
"relative_pod": "source_or_derived"
},
{
"assertion_status": "source_asserted_not_complication",
"document_id": "DOCUMENT-0000004",
"episode_id": "EPISODE-0000001",
"observation_id": "OBSERVATION-0000004",
"relative_pod": "source_or_derived"
},
{
"assertion_status": "source_asserted_not_complication",
"document_id": "DOCUMENT-0000005",
"episode_id": "EPISODE-0000001",
"observation_id": "OBSERVATION-0000005",
"relative_pod": "source_or_derived"
},
{
"assertion_status": "source_asserted_not_complication",
"document_id": "DOCUMENT-0000006",
"episode_id": "EPISODE-0000001",
"observation_id": "OBSERVATION-0000006",
"relative_pod": "source_or_derived"
},
{
"assertion_status": "source_asserted_not_complication",
"document_id": "DOCUMENT-0000007",
"episode_id": "EPISODE-0000001",
"observation_id": "OBSERVATION-0000007",
"relative_pod": "source_or_derived"
},
{
"assertion_status": "source_asserted_not_complication",
"document_id": "DOCUMENT-0000008",
"episode_id": "EPISODE-0000001",
"observation_id": "OBSERVATION-0000008",
"relative_pod": "source_or_derived"
},
{
"assertion_status": "source_asserted_not_complication",
"document_id": "DOCUMENT-0000009",
"episode_id": "EPISODE-0000001",
"observation_id": "OBSERVATION-0000009",
"relative_pod": "source_or_derived"
},
{
"assertion_status": "source_asserted_not_complication",
"document_id": "DOCUMENT-0000010",
"episode_id": "EPISODE-0000001",
"observation_id": "OBSERVATION-0000010",
"relative_pod": "source_or_derived"
}
],
"clinical_outcome": {
"coverage_status": "no_30_day_followup",
"episode_id": "EPISODE-0000001",
"outcome_id": "OUTCOME-0000001",
"outcome_time": "2026-07-29 08:08:16",
"outcome_type": "discharge"
},
"quality_issue": [
{
"handling": "symptoms and findings are not upgraded",
"issue_code": "complication_truth_zero",
"quality_issue_id": "QUALITY_ISSUE-0000001"
},
{
"handling": "no 30-day negative outcome claim",
"issue_code": "post_discharge_coverage_unknown",
"quality_issue_id": "QUALITY_ISSUE-0000002"
}
]
}