临床文书分类与章节切分数据 · 数巨有谱数据集团

项	数量	内容
实体	6	临床文书 · 文书分类 · 文书版本 · 章节跨度 · 数据质量项 · 来源沿袭
字段	47	交付范围内的字段总数
实体关系	4	文书 1—n 文书版本 1—n 章节跨度 · 每份文书带文书级来源沿袭与具名的配套正文对象 · 文书族、来源文书类型、来源标题与规范子类型四者分列保存 · 来源未给出边界证据的位置不生成章节

项

数量

内容

实体

临床文书 · 文书分类 · 文书版本 · 章节跨度 · 数据质量项 · 来源沿袭

字段

交付范围内的字段总数

实体关系

文书 1—n 文书版本 1—n 章节跨度 · 每份文书带文书级来源沿袭与具名的配套正文对象 · 文书族、来源文书类型、来源标题与规范子类型四者分列保存 · 来源未给出边界证据的位置不生成章节

对象	英文键	中文名
临床文书	document_id	文书标识
临床文书	document_family	文书族
临床文书	sourcedocumenttype	来源文书类型
临床文书	sourcedocumenttitle
临床文书	normalized_subtype
临床文书	sourcedocumentid_status	来源文书标识状态
临床文书	normalizationruleid
临床文书	replay_mode
临床文书	companionassetid
临床文书	normalized_text	规范化文本
临床文书	recordedtimeraw	记录时间
临床文书	content_sha256	正文校验值
临床文书	data_nature	数据性质
文书分类	classification_id
文书分类	document_id	文书标识
文书分类	document_family	文书族
文书分类	sourcedocumenttype	来源文书类型
文书分类	sourcedocumenttitle
文书分类	normalized_subtype
文书分类	data_nature	数据性质
文书版本	documentversionid	文书版本标识
文书版本	document_id	文书标识
文书版本	version_status	版本状态
文书版本	content_sha256	正文校验值
文书版本	normalizedtextasset_id
文书版本	data_nature	数据性质
数据质量项	qualityissueid	数据质量项标识
数据质量项	document_id	文书标识
数据质量项	issue_code	问题代码
数据质量项	handling	处理方式
数据质量项	data_nature	数据性质
章节片段	section_id	章节标识
章节片段	documentversionid	文书版本标识
章节片段	normalizationruleid
章节片段	sectionnameraw	章节名称
章节片段	section_type	章节类型
章节片段	start_offset	起始偏移
章节片段	end_offset	结束偏移
章节片段	boundary_evidence
章节片段	data_nature	数据性质
来源沿袭	sourcelineageid	来源沿袭标识
来源沿袭	document_id	文书标识
来源沿袭	sourceassetid	来源资产标识
来源沿袭	logicalsourceuri
来源沿袭	companionassetid
来源沿袭	normalizationruleid
来源沿袭	data_nature	数据性质

起	基数	至	关系语义
临床文书	1—n	文书版本	一份文书的多个正文版本，各带独立正文指纹
文书版本	1—n	章节跨度	版本内按字符偏移定位的章节跨度，无边界证据的版本为零章节
临床文书	1—1	文书分类	一份文书一条分类结果，四层分类值同行并存
临床文书	1—n	数据质量项	文书标识层面的问题登记
临床文书	1—1	来源沿袭	文书级来源沿袭，含配套正文对象与规则版本

起

基数

至

关系语义

临床文书

1—n

文书版本

一份文书的多个正文版本，各带独立正文指纹

文书版本

1—n

章节跨度

版本内按字符偏移定位的章节跨度，无边界证据的版本为零章节

临床文书

1—1

文书分类

一份文书一条分类结果，四层分类值同行并存

临床文书

1—n

数据质量项

文书标识层面的问题登记

临床文书

1—1

来源沿袭

文书级来源沿袭，含配套正文对象与规则版本

分组	字段	英文键	语义
临床文书	文书族	document_family	文书的粗粒度归属，本例含门诊、入院、首次病程、病程与查房、手术、出院六类；粒度粗于来源文书类型，用于跨机构对齐
临床文书	来源文书类型	sourcedocumenttype	来源系统登记的文书类型名称，按原值保留；来源未写明时如实记为类型缺失，不按标题或存放位置回填
临床文书	来源文书标题	sourcedocumenttitle	文书在来源系统中的标题，与类型分列。本例含日常病程记录、首次病程记录、转入记录、转出记录等写法
临床文书	规范子类型	normalized_subtype	文书族之下的细分类别。本例二十一份病程与查房文书还有细分，含日常病程、首次查房、其他日常查房、转科等类别
临床文书	来源文书编号状态	sourcedocumentid_status	来源文书编号的可用状态，取正常、重复、缺失之一；重复或缺失时改用内部标识归集
临床文书	正文回放方式	replay_mode	章节偏移回放到正文的方式；本例正文以配套对象交付，须叠加该对象才能按偏移取回片段
临床文书	配套正文对象标识	companionassetid	承载规范化正文的配套对象；正文与结构表分开交付，字符偏移以该对象的字符序为准
临床文书	规范化正文	normalized_text	按声明规则做过字符规范化的文书正文，章节起止偏移以它的 Unicode 字符序计
临床文书	规范化规则版本	normalizationruleid	产生本条正文与偏移的规则版本；规则升级另出一版
临床文书	记录时间	recordedtimeraw	来源系统登记该文书的时点；来源为空即留空
文书版本	版本状态	version_status	该正文版本在来源系统中的状态；本例来源未留签发与更正痕迹，如实记为版本未知，不假定为终版
文书版本	正文内容校验值	content_sha256	该版本正文的内容指纹，用于判断两份文书是否同一份正文
章节跨度	章节名称	sectionnameraw	来源中出现的章节标题。本例含主诉、现病史、入院诊断、诊疗计划、术前诊断、术后诊断、出院诊断、诊疗经过
章节跨度	章节类型	section_type	章节标题归一后的类别，与来源标题分列；两者取值相同时也各存一份，便于日后规则变更
章节跨度	起始偏移与结束偏移	startoffset／endoffset	章节在规范化正文中的字符区间，左闭右开；按该区间截取即得原片段
章节跨度	边界证据	boundary_evidence	这条边界的来源依据；本例十二个章节全部出自来源结构字段，并可叠加配套正文对象回放
数据质量项	问题代码	issue_code	该文书上登记的问题类别，本例为来源文书编号重复与来源文书编号缺失两类
数据质量项	处理方式	handling	问题的处理口径：来源编号的主键适用状态按文书逐份保留，随数据一同交付
来源沿袭	来源对象标识	sourceassetid	该文书所出自的来源对象登记位，使每份文书都能回指到它的出处

分组

字段

英文键

语义

临床文书

文书族

document_family

文书的粗粒度归属，本例含门诊、入院、首次病程、病程与查房、手术、出院六类；粒度粗于来源文书类型，用于跨机构对齐

临床文书

来源文书类型

sourcedocumenttype

来源系统登记的文书类型名称，按原值保留；来源未写明时如实记为类型缺失，不按标题或存放位置回填

临床文书

来源文书标题

sourcedocumenttitle

文书在来源系统中的标题，与类型分列。本例含日常病程记录、首次病程记录、转入记录、转出记录等写法

临床文书

规范子类型

normalized_subtype

文书族之下的细分类别。本例二十一份病程与查房文书还有细分，含日常病程、首次查房、其他日常查房、转科等类别

临床文书

来源文书编号状态

sourcedocumentid_status

来源文书编号的可用状态，取正常、重复、缺失之一；重复或缺失时改用内部标识归集

临床文书

正文回放方式

replay_mode

章节偏移回放到正文的方式；本例正文以配套对象交付，须叠加该对象才能按偏移取回片段

临床文书

配套正文对象标识

companionassetid

承载规范化正文的配套对象；正文与结构表分开交付，字符偏移以该对象的字符序为准

临床文书

规范化正文

normalized_text

按声明规则做过字符规范化的文书正文，章节起止偏移以它的 Unicode 字符序计

临床文书

规范化规则版本

normalizationruleid

产生本条正文与偏移的规则版本；规则升级另出一版

临床文书

记录时间

recordedtimeraw

来源系统登记该文书的时点；来源为空即留空

文书版本

版本状态

version_status

该正文版本在来源系统中的状态；本例来源未留签发与更正痕迹，如实记为版本未知，不假定为终版

文书版本

正文内容校验值

content_sha256

该版本正文的内容指纹，用于判断两份文书是否同一份正文

章节跨度

章节名称

sectionnameraw

来源中出现的章节标题。本例含主诉、现病史、入院诊断、诊疗计划、术前诊断、术后诊断、出院诊断、诊疗经过

章节跨度

章节类型

section_type

章节标题归一后的类别，与来源标题分列；两者取值相同时也各存一份，便于日后规则变更

章节跨度

起始偏移与结束偏移

startoffset／endoffset

章节在规范化正文中的字符区间，左闭右开；按该区间截取即得原片段

章节跨度

边界证据

boundary_evidence

这条边界的来源依据；本例十二个章节全部出自来源结构字段，并可叠加配套正文对象回放

数据质量项

问题代码

issue_code

该文书上登记的问题类别，本例为来源文书编号重复与来源文书编号缺失两类

数据质量项

处理方式

handling

问题的处理口径：来源编号的主键适用状态按文书逐份保留，随数据一同交付

来源沿袭

来源对象标识

sourceassetid

该文书所出自的来源对象登记位，使每份文书都能回指到它的出处

{ "样例性质": "真实记录·已脱敏", "clinical_document": [ { "document_family": "outpatient", "document_id": "DOCUMENT-0000001", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "outpatient", "normalized_text": null, "recorded_time_raw": null, "replay_mode": "companion_text_overlay_required", "source_document_id_status": "missing", "source_document_title": null, "source_document_type": "source_type_missing" }, { "document_family": "admission", "document_id": "DOCUMENT-0000002", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "admission", "normalized_text": null, "recorded_time_raw": null, "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": null, "source_document_type": "source_type_missing" }, { "document_family": "first_course", "document_id": "DOCUMENT-0000003", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "first_course", "normalized_text": null, "recorded_time_raw": "2026-07-14T16:54:51", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "duplicate", "source_document_title": null, "source_document_type": "source_type_missing" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000004", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "first_course_in_progress", "normalized_text": null, "recorded_time_raw": "2026-07-14T16:54:51", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "duplicate", "source_document_title": "首次病程记录", "source_document_type": "首次病程记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000005", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "initial_round", "normalized_text": null, "recorded_time_raw": "2026-07-15T08:08:43", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "医生I职称B首次查房记录", "source_document_type": "（首次）查房记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000006", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "initial_round", "normalized_text": null, "recorded_time_raw": "2026-07-16T12:06:48", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "医生P职称C首次查房记录", "source_document_type": "（首次）查房记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000007", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "transfer", "normalized_text": null, "recorded_time_raw": "2026-07-17T09:12:53", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "转出记录", "source_document_type": "转科记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000008", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "transfer", "normalized_text": null, "recorded_time_raw": "2026-07-17T10:40:05", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "转入记录", "source_document_type": "转科记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000009", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "initial_round", "normalized_text": null, "recorded_time_raw": "2026-07-18T15:08:30", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "医生C职称B查房记录(首次)", "source_document_type": "（首次）查房记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000010", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "daily_progress", "normalized_text": null, "recorded_time_raw": "2026-07-18T17:09:18", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000011", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "initial_round", "normalized_text": null, "recorded_time_raw": "2026-07-19T09:10:54", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "医生H职称C查房记录(首次)", "source_document_type": "（首次）查房记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000012", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "daily_progress", "normalized_text": null, "recorded_time_raw": "2026-07-19T15:13:08", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000013", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "preoperative_discussion", "normalized_text": null, "recorded_time_raw": "2026-07-19T16:35:05", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "术前讨论记录", "source_document_type": "术前讨论" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000014", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "preoperative_summary", "normalized_text": null, "recorded_time_raw": "2026-07-19T17:17:15", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "术前小结", "source_document_type": "术前小结" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000015", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "postoperative_first_course", "normalized_text": null, "recorded_time_raw": "2026-07-20T15:55:23", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "术后首次病程记录", "source_document_type": "术后首次病程记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000016", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "daily_progress", "normalized_text": null, "recorded_time_raw": "2026-07-21T07:43:17", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "中医治疗协作会诊申请", "source_document_type": "日常病程记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000017", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "other_daily_round", "normalized_text": null, "recorded_time_raw": "2026-07-21T09:09:50", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "医生C职称B查房记录", "source_document_type": "其他日常查房记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000018", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "daily_progress", "normalized_text": null, "recorded_time_raw": "2026-07-21T11:57:27", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "中医治疗协作会诊记录", "source_document_type": "日常病程记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000019", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "daily_progress", "normalized_text": null, "recorded_time_raw": "2026-07-21T17:12:53", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000020", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "daily_progress", "normalized_text": null, "recorded_time_raw": "2026-07-22T09:14:20", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000021", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "daily_progress", "normalized_text": null, "recorded_time_raw": "2026-07-23T10:38:59", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000022", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "other_daily_round", "normalized_text": null, "recorded_time_raw": "2026-07-26T08:53:14", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "医生H职称C查房记录", "source_document_type": "其他日常查房记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000023", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "daily_progress", "normalized_text": null, "recorded_time_raw": "2026-07-26T16:55:26", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "document_family": "progress_round", "document_id": "DOCUMENT-0000024", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "daily_progress", "normalized_text": null, "recorded_time_raw": "2026-07-29T08:47:55", "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "document_family": "operative", "document_id": "DOCUMENT-0000025", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "operative", "normalized_text": null, "recorded_time_raw": null, "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": null, "source_document_type": "source_type_missing" }, { "document_family": "discharge", "document_id": "DOCUMENT-0000026", "normalization_rule_id": "NORMALIZATION_RULE-0000001", "normalized_subtype": "discharge", "normalized_text": null, "recorded_time_raw": null, "replay_mode": "companion_text_overlay_required", "source_document_id_status": "present", "source_document_title": null, "source_document_type": "source_type_missing" } ], "document_classification": [ { "classification_id": "CLASSIFICATION-0000001", "document_family": "outpatient", "document_id": "DOCUMENT-0000001", "normalized_subtype": "outpatient", "source_document_title": null, "source_document_type": "source_type_missing" }, { "classification_id": "CLASSIFICATION-0000002", "document_family": "admission", "document_id": "DOCUMENT-0000002", "normalized_subtype": "admission", "source_document_title": null, "source_document_type": "source_type_missing" }, { "classification_id": "CLASSIFICATION-0000003", "document_family": "first_course", "document_id": "DOCUMENT-0000003", "normalized_subtype": "first_course", "source_document_title": null, "source_document_type": "source_type_missing" }, { "classification_id": "CLASSIFICATION-0000004", "document_family": "progress_round", "document_id": "DOCUMENT-0000004", "normalized_subtype": "first_course_in_progress", "source_document_title": "首次病程记录", "source_document_type": "首次病程记录" }, { "classification_id": "CLASSIFICATION-0000005", "document_family": "progress_round", "document_id": "DOCUMENT-0000005", "normalized_subtype": "initial_round", "source_document_title": "医生I职称B首次查房记录", "source_document_type": "（首次）查房记录" }, { "classification_id": "CLASSIFICATION-0000006", "document_family": "progress_round", "document_id": "DOCUMENT-0000006", "normalized_subtype": "initial_round", "source_document_title": "医生P职称C首次查房记录", "source_document_type": "（首次）查房记录" }, { "classification_id": "CLASSIFICATION-0000007", "document_family": "progress_round", "document_id": "DOCUMENT-0000007", "normalized_subtype": "transfer", "source_document_title": "转出记录", "source_document_type": "转科记录" }, { "classification_id": "CLASSIFICATION-0000008", "document_family": "progress_round", "document_id": "DOCUMENT-0000008", "normalized_subtype": "transfer", "source_document_title": "转入记录", "source_document_type": "转科记录" }, { "classification_id": "CLASSIFICATION-0000009", "document_family": "progress_round", "document_id": "DOCUMENT-0000009", "normalized_subtype": "initial_round", "source_document_title": "医生C职称B查房记录(首次)", "source_document_type": "（首次）查房记录" }, { "classification_id": "CLASSIFICATION-0000010", "document_family": "progress_round", "document_id": "DOCUMENT-0000010", "normalized_subtype": "daily_progress", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "classification_id": "CLASSIFICATION-0000011", "document_family": "progress_round", "document_id": "DOCUMENT-0000011", "normalized_subtype": "initial_round", "source_document_title": "医生H职称C查房记录(首次)", "source_document_type": "（首次）查房记录" }, { "classification_id": "CLASSIFICATION-0000012", "document_family": "progress_round", "document_id": "DOCUMENT-0000012", "normalized_subtype": "daily_progress", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "classification_id": "CLASSIFICATION-0000013", "document_family": "progress_round", "document_id": "DOCUMENT-0000013", "normalized_subtype": "preoperative_discussion", "source_document_title": "术前讨论记录", "source_document_type": "术前讨论" }, { "classification_id": "CLASSIFICATION-0000014", "document_family": "progress_round", "document_id": "DOCUMENT-0000014", "normalized_subtype": "preoperative_summary", "source_document_title": "术前小结", "source_document_type": "术前小结" }, { "classification_id": "CLASSIFICATION-0000015", "document_family": "progress_round", "document_id": "DOCUMENT-0000015", "normalized_subtype": "postoperative_first_course", "source_document_title": "术后首次病程记录", "source_document_type": "术后首次病程记录" }, { "classification_id": "CLASSIFICATION-0000016", "document_family": "progress_round", "document_id": "DOCUMENT-0000016", "normalized_subtype": "daily_progress", "source_document_title": "中医治疗协作会诊申请", "source_document_type": "日常病程记录" }, { "classification_id": "CLASSIFICATION-0000017", "document_family": "progress_round", "document_id": "DOCUMENT-0000017", "normalized_subtype": "other_daily_round", "source_document_title": "医生C职称B查房记录", "source_document_type": "其他日常查房记录" }, { "classification_id": "CLASSIFICATION-0000018", "document_family": "progress_round", "document_id": "DOCUMENT-0000018", "normalized_subtype": "daily_progress", "source_document_title": "中医治疗协作会诊记录", "source_document_type": "日常病程记录" }, { "classification_id": "CLASSIFICATION-0000019", "document_family": "progress_round", "document_id": "DOCUMENT-0000019", "normalized_subtype": "daily_progress", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "classification_id": "CLASSIFICATION-0000020", "document_family": "progress_round", "document_id": "DOCUMENT-0000020", "normalized_subtype": "daily_progress", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "classification_id": "CLASSIFICATION-0000021", "document_family": "progress_round", "document_id": "DOCUMENT-0000021", "normalized_subtype": "daily_progress", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "classification_id": "CLASSIFICATION-0000022", "document_family": "progress_round", "document_id": "DOCUMENT-0000022", "normalized_subtype": "other_daily_round", "source_document_title": "医生H职称C查房记录", "source_document_type": "其他日常查房记录" }, { "classification_id": "CLASSIFICATION-0000023", "document_family": "progress_round", "document_id": "DOCUMENT-0000023", "normalized_subtype": "daily_progress", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "classification_id": "CLASSIFICATION-0000024", "document_family": "progress_round", "document_id": "DOCUMENT-0000024", "normalized_subtype": "daily_progress", "source_document_title": "日常病程记录", "source_document_type": "日常病程记录" }, { "classification_id": "CLASSIFICATION-0000025", "document_family": "operative", "document_id": "DOCUMENT-0000025", "normalized_subtype": "operative", "source_document_title": null, "source_document_type": "source_type_missing" }, { "classification_id": "CLASSIFICATION-0000026", "document_family": "discharge", "document_id": "DOCUMENT-0000026", "normalized_subtype": "discharge", "source_document_title": null, "source_document_type": "source_type_missing" } ], "document_version": [ { "document_id": "DOCUMENT-0000001", "document_version_id": "DOCUMENT_VERSION-0000001", "version_status": "source_version_unknown" }, { "document_id": "DOCUMENT-0000002", "document_version_id": "DOCUMENT_VERSION-0000002", "version_status": "source_version_unknown" }, { "document_id": "DOCUMENT-0000003", "document_version_id": "DOCUMENT_VERSION-0000003", "version_status": "source_version_unknown" }, { "document_id": "DOCUMENT-0000004", "document_version_id": "DOCUMENT_VERSION-0000004", "version_status": "source_version_unknown" }, { "document_id": "DOCUMENT-0000005", "document_version_id": "DOCUMENT_VERSION-0000005", "version_status": "source_version_unknown" }, { "document_id": "DOCUMENT-0000006", "document_version_id": "DOCUMENT_VERSION-0000006", "version_status": "source_version_unknown" }, { "document_id": "DOCUMENT-0000007", "document_version_id": "DOCUMENT_VERSION-0000007", "version_status": "source_version_unknown" }, { "document_id": "DOCUMENT-0000008", "document_version_id": "DOCUMENT_VERSION-0000008", "version_status": "source_version_unknown" }, { "document_id": "DOCUMENT-0000009", "document_version_id": "DOCUMENT_VERSION-0000009", "version_status": "source_version_unknown" }, { "document_id": "DOCUMENT-0000010", "document_version_id": 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"诊疗经过", "section_type": "诊疗经过", "start_offset": 455 } ], "quality_issue": [ { "document_id": "DOCUMENT-0000001", "handling": "preserve non-primary source-id quality state per document", "issue_code": "missing_source_document_id", "quality_issue_id": "QUALITY_ISSUE-0000001" }, { "document_id": "DOCUMENT-0000003", "handling": "preserve non-primary source-id quality state per document", "issue_code": "duplicate_source_document_id", "quality_issue_id": "QUALITY_ISSUE-0000002" }, { "document_id": "DOCUMENT-0000004", "handling": "preserve non-primary source-id quality state per document", "issue_code": "duplicate_source_document_id", "quality_issue_id": "QUALITY_ISSUE-0000003" } ] }

[03]

使用场景

文书分类与章节切分模型的训练语料组织

医疗科技企业 · 临床自然语言处理平台团队

四层标签同时可用：文书族、来源文书类型、来源标题与规范子类型分列存放。可按任一层做标签，也可训练由细到粗的层级分类
细分类的真实难点摆在面上：本例二十一份病程与查房文书还有细分。含日常病程、首次查房、其他日常查房、转科等类别。同族内部标题写法相近，可作为分类模型的难例来源
切分任务带边界依据：每个章节跨度带起止字符偏移与边界证据。训练切分模型时可只采用有来源依据的边界作正样本
零章节文书按未标注处理：未切出章节表示来源未给出显式边界，训练时按未标注处理
规则版本随样本走：正文与偏移都绑定规范化规则版本。规则升级后新旧语料可并存对比，无须回改历史标注

获得：标签分层清楚、边界有依据、可随规则版本演进的文书语料

病历书写与留痕能力的逐份核对

三甲医院 · 病案与病历质量部门

类型与标题对不上先查：来源文书类型与来源标题分列，可直接筛出标题写法与类型登记不一致的文书
编号可用性盘点：来源文书编号状态区分正常、重复、缺失。本例二十六份中有两份编号重复、一份缺号。据此可定位院内编号规则的薄弱环节
必备章节到位程度：看主诉、现病史、入院诊断这类章节的实际出现情况。据此核对各类文书的必备项到位程度
留痕能力可见：文书版本状态如实记为未知，说明来源系统未保留签发与更正痕迹。可作为病历留痕改进的依据
结论能回到具体文书：每条问题带问题代码与处理方式并挂在文书标识上，核对结论可逐份回查

获得：可逐份定位到文书的书写规范与留痕能力盘点结果

病历章节级检索与展示功能的底层数据

医疗信息化企业 · 电子病历产品团队

按区间精确定位：章节起止偏移左闭右开，前端按区间截取即得该章节片段，不必再跑一遍文本匹配
正文与结构分开取：正文以配套对象交付，结构表只存偏移。检索索引可只建在结构表上，正文按需加载
重复正文可识别：正文内容校验值可判断两份文书是否同一份正文。复制粘贴产生的雷同病程记录可据此在检索结果中识别
映射升级可回退：来源类型到规范子类型的映射随规则版本记录。产品升级映射后，旧数据仍可按旧版还原
零章节是正常态：文书允许没有章节。展示层据此可设计成「该文书未提供章节结构」

获得：可直接驱动章节级检索与展示的文书结构底表

按文书类型与章节精确取材

医学研究团队 · 队列构建与文本二次利用

先按类型圈定文书：以文书族与规范子类型圈定入院记录、首次病程、手术记录、出院记录。查房记录另成一类，取材时可分开处理
只取需要的那一段：研究只需现病史或出院诊断时，按章节类型取对应区间。不必把整份文书送进下游处理
文书时间单独成列：文书记录时间与正文中提到的日期分开保存。构建时间线时按文书记录时间取值
取材可被他人复现：文书标识、版本标识、规则版本与字符区间四项共同确定一段取材。他人按同样四项能取到同一段文字

获得：取材范围明确、他人可按同一坐标复现的文本二次利用底料

[04]

定制与定向

是否支持定制：是
章节切分范围（单选）：只按来源结构字段边界 / 结构字段边界＋显式正文小标题
其他定制项（多选）：文书类型范围 / 科室范围 / 医院等级 / 文书时间范围 / 章节类型范围
最低定制数量：20,000 份临床文书
正文交付形态：规范化正文可随结构表一同交付，或只交付结构与偏移、正文按项目另行约定
其他可定制项：与项目商务确定

[05]

去标识化与交付

直接标识符移除：姓名、证件号码、联系方式、住址
间接标识符不可逆映射：患者标识、就诊号、报告单号
时间平移：整体平移并保持时序与时间间隔
机构与医师信息去除或泛化
自由文本二次核查：叙述内容中的标识信息
可按项目追加 K-匿名等泛化处理，匿名化的判定与出具方式随项目约定
文书正文与章节片段二次核查：患者与家属姓名、联系方式、住址、床号、工号去除；医师姓名与职称改为角色占位，占位在同一批文书内保持一致
文书记录时间统一平移，保序保间隔；正文中出现的日期同步平移
章节字符偏移随替换后的正文重算，按偏移截取仍落在同一段内容上

加密通道交付：支持

[06]

关联数据集

SHP-MED-05-032 临床实体与关系标注数据——在文书正文之上的实体与关系标注层
SHP-MED-05-035 临床文本去标识化数据——同类文书的去标识化结果与替换台账
SHP-MED-01-002 住院诊疗数据——文书所依附的住院过程结构数据

[07]

常见问题

临床文书分类与章节切分数据包含哪些内容？

临床文书分类与章节切分数据（SHP-MED-05-031）交付临床文书的分类与章节切分结果：每份文书归入文书族与规范子类型，正文按声明规则规范化后另存版本，章节以字符起止偏移标出并附边界证据，来源标题与编号状态一并保留。

临床文书分类与章节切分数据适合做什么？

适合文书分类与章节切分模型训练，四层标签支持由细到粗的层级分类，病程与查房文书的近义标题细分类是现成难例；也适合病历书写与留痕能力的逐份核对、章节级检索与展示功能建设，以及按文书类型与章节精确取材的研究。

临床文书分类与章节切分数据有样例吗？怎么交付？

产品页提供真实脱敏样例：二十六份临床文书的分类结果，其中门诊、入院、首次病程、手术、出院五份切出十二个带字符偏移与边界证据的章节跨度。交付形态含数据集（CSV／Parquet 加对象文件夹）、API 调用、Token 计量与可信数据空间连接器。

临床文书分类与章节切分数据如何定制与起步？

章节切分范围可选只按来源结构字段边界，或加上显式正文小标题，再按文书类型、科室、医院等级、文书时间与章节类型筛选，起订量为 20,000 份临床文书，数据量按项目商定。可先申请开源子集或测试数据核对偏移口径。

临床文书分类与章节切分数据与哪些产品搭配？

常与临床实体与关系标注数据（SHP-MED-05-032）叠加正文之上的实体与关系标注层，与临床文本去标识化数据（SHP-MED-05-035）衔接同类文书的去标识结果与替换台账，与住院诊疗数据（SHP-MED-01-002）关联文书所依附的住院过程。

[08]

获取方式

有明确科研／临床项目：提供研究方向与所需字段范围，可先申请开源子集用于可行性验证。
有明确数据智能场景：提供模型或应用场景，可先申请测试数据与接入方式完成联调。
许可：评估与研究使用许可。

临床文书分类与章节切分数据。

读懂数据结构与交付边界

数据产品概览

交付与供应方式

权利与来源

数据内容与字段结构

实体概览

临床文书

文书分类

文书版本

章节跨度

数据质量项

来源沿袭

连接关系

样例字段语义

样例记录

使用场景

文书分类与章节切分模型的训练语料组织

病历书写与留痕能力的逐份核对

病历章节级检索与展示功能的底层数据

按文书类型与章节精确取材

定制与定向

去标识化与交付

关联数据集

常见问题

获取方式

继续查看可连接的数据产品

临床实体与关系标注数据

临床文本去标识化数据

患者住院诊疗数据