一次护理服务过程中的评估与再评估记录。含入院护理评估基线、按槽序展开的专项复评序列，以及同槽位记录的来源措施项。护理问题、计划、措施、复评与护理结局随片段组织。可用于护理量表结构化训练、复评节律核查与护理服务评价。
围术期、重症与护理 · 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 | 12 | 护理片段 · 入院护理评估 · 评估序列 · 评估槽位 · 槽内措施项 · 护理问题 · 护理计划 · 护理措施 · 复评 · 护理结局 · 来源沿袭 · 数据质量项 |
| 字段 | 68 | 交付范围内的字段总数 |
| 实体关系 | 2 | 评估与措施在同一来源行的同一槽位上关联，该关联表示结构对应 · 跨文书的患者级护理片段须有稳定标识或正式对照表方可成立，未成立时逐条声明为未挂接 |
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 |
|---|---|---|---|
| 入院护理评估 | admissionassessmentid | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 | |
| 入院护理评估 | 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。 |
| 入院护理评估 | assessmentdateraw | 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。 | |
| 入院护理评估 | 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。 |
| 入院护理评估 | fallscoreraw | 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。 | |
| 入院护理评估 | pressurescoreraw | 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。 | |
| 入院护理评估 | painscoreraw | 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。 | |
| 入院护理评估 | selfcarescore_raw | 自理能力评分 | 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。 |
| 入院护理评估 | vtescoreraw | 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。 | |
| 入院护理评估 | 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。 |
| 评估槽位 | assessment_id | 评估标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 评估槽位 | series_id | 序列标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 评估槽位 | slot_no | 与该表业务对象直接相关的文本属性。 | |
| 评估槽位 | assessmentdateraw | 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。 | |
| 评估槽位 | 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。 |
| 评估槽位 | totalscoreraw | 总分 | 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。 |
| 评估槽位 | score_validity | 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。 | |
| 评估槽位 | 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。 |
| 评估槽位 | 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。 |
| 护理计划 | plan_id | 计划标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 护理计划 | problem_id | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 | |
| 护理计划 | plan_status | 计划状态 | 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。 |
| 护理计划 | 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。 |
| 护理片段 | episode_id | 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。 |
| 护理片段 | patient_id | 患者ID | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 护理片段 | encounter_id | 就诊号 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 护理片段 | episode_status | 轨迹状态 | 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。 |
| 护理片段 | 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。 |
| 护理措施 | intervention_id | 干预标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 护理措施 | plan_id | 计划标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 护理措施 | implementation_time | 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。 | |
| 护理措施 | execution_status | 执行状态 | 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。 |
| 护理措施 | 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。 |
| 护理结局 | outcome_id | 结局标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 护理结局 | episode_id | 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。 |
| 护理结局 | outcome_status | 结果状态 | 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。 |
| 护理结局 | coverage_status | 覆盖状态 | 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。 |
| 护理结局 | 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。 |
| 护理问题 | problem_id | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 | |
| 护理问题 | episode_id | 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。 |
| 护理问题 | problemnameraw | 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。 | |
| 护理问题 | 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。 |
| 护理评估序列候选 | series_id | 序列标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 护理评估序列候选 | 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。 |
| 护理评估序列候选 | series_status | 序列状态 | 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。 |
| 护理评估序列候选 | crossfilelinkage_status | 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。 | |
| 护理评估序列候选 | 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。 |
| 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 | issue_code | 问题代码 | 与该表业务对象直接相关的文本属性。 |
| 数据质量项 | handling | 处理方式 | 与该表业务对象直接相关的文本属性。 |
| 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。 |
| 复评 | reassessment_id | 复评标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 复评 | assessment_id | 评估标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 复评 | priorassessmentid | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 | |
| 复评 | causaleffectstatus | 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。 | |
| 复评 | 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 | sourcelineageid | 来源沿袭标识 | 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 | sourceassetid | 来源资产标识 | 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 | logicalsourceuri | 与该表业务对象直接相关的文本属性。 | |
| 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 | 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。 |
| 槽内措施项 | measure_id | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 | |
| 槽内措施项 | assessment_id | 评估标识 | 稳定对象标识或连接键；用于逐表关联，不承载临床结论。 |
| 槽内措施项 | measurenameraw | 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。 | |
| 槽内措施项 | measurevalueraw | 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。 | |
| 槽内措施项 | measure_status | 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。 | |
| 槽内措施项 | implementation_time | 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。 | |
| 槽内措施项 | 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。 |
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。
患者令牌 · 片段状态
五类量表并列
序列状态 · 挂接状态
槽序 · 总分 · 有效性
措施名称 · 措施状态
问题名称
计划状态
实施时间 · 执行状态
前序评估 · 效果判定
结果状态 · 覆盖状态
source_lineage
quality_issue
每条关系独占一行，基数置于两实体之间
评估序列
序列状态 · 挂接状态
评估槽位
槽序 · 总分 · 有效性
评估槽位
槽序 · 总分 · 有效性
槽内措施项
措施名称 · 措施状态
评估槽位
槽序 · 总分 · 有效性
复评
前序评估 · 效果判定
护理片段
患者令牌 · 片段状态
护理问题
问题名称
护理问题
问题名称
护理计划
计划状态
护理计划
计划状态
护理措施
实施时间 · 执行状态
护理片段
患者令牌 · 片段状态
护理结局
结果状态 · 覆盖状态
评估序列
序列状态 · 挂接状态
护理片段
患者令牌 · 片段状态
入院护理评估
五类量表并列
护理片段
患者令牌 · 片段状态
护理措施
实施时间 · 执行状态
复评
前序评估 · 效果判定
| 起 | 基数 | 至 | 关系语义 |
|---|---|---|---|
| 评估序列 | 1—n | 评估槽位 | 一条评估序列按槽序展开为多次评估 |
| 评估槽位 | 1—n | 槽内措施项 | 同一槽位内记录的来源措施项 |
| 评估槽位 | 1—n | 复评 | 同一序列内后一次评估相对前一次构成复评 |
| 护理片段 | 1—n | 护理问题 | 片段下提出的护理问题 |
| 护理问题 | 1—n | 护理计划 | 针对同一问题制定的护理计划 |
| 护理计划 | 1—n | 护理措施 | 计划之下带实施时间与执行状态的护理措施 |
| 护理片段 | 1—n | 护理结局 | 片段下的护理结局及其覆盖状态 |
| 评估序列 | n—1 | 护理片段 | 序列归入哪一段患者级护理片段，须有稳定标识或正式对照表 |
| 入院护理评估 | n—1 | 护理片段 | 入院评估作为片段基线的挂接同样以标识确证为条件 |
| 护理措施 | 1—n | 复评 | 措施与复评之间的效果关系显式声明 |
评估序列按槽序展开为多次评估，措施项挂在其所属的那一次评估之下。护理问题、计划、措施与结局沿护理片段自上而下组织。评估序列与入院评估归入哪一段患者级护理片段，取决于稳定标识或正式对照表。措施与复评之间的效果关系须显式声明。
| 分组 | 字段 | 英文键 | 语义 |
|---|---|---|---|
| 评估序列 | 序列状态 | series_status | 该序列的成立方式，声明它由同一来源行的多个槽位组成 |
| 评估序列 | 跨文书挂接状态 | crossfilelinkage_status | 该序列与其他护理文书的挂接情况；标识不足以确证时逐条声明，不拼成患者级历程 |
| 评估槽位 | 槽序 | slot_no | 该次评估在同一来源行中的次序，与来源行标识合用可原样回放到宽表位置 |
| 评估槽位 | 评估日期 | assessmentdateraw | 该次评估的日期，与评估时间分列保存 |
| 评估槽位 | 评估时间 | assessmenttimeraw | 该次评估的时点；来源只写日期时不自行补造时点 |
| 评估槽位 | 总分 | totalscoreraw | 该次评估的总分原值；来源单元格为空时保持空缺，不以 0 代入 |
| 评估槽位 | 分值有效性 | score_validity | 该槽位是否取得有效分值；日期与分值两项分别判断 |
| 评估槽位 | 缺失原因 | missing_reason | 分值缺失的具体原因，随数据交付，供研究决定是否剔除该次评估 |
| 入院护理评估 | 跌倒坠床风险评分 | fallscoreraw | 入院时跌倒坠床风险的来源评分；非数值取值如「未涉及」原样保留，不映射为分数 |
| 入院护理评估 | 压力性损伤评分 | pressurescoreraw | 入院时压力性损伤风险的来源评分，按来源量表口径记录 |
| 入院护理评估 | 疼痛评分 | painscoreraw | 入院时疼痛程度的来源评分 |
| 入院护理评估 | 自理能力评分 | selfcarescore_raw | 入院时日常生活自理能力的来源评分，分值方向随所用量表声明 |
| 入院护理评估 | 静脉血栓栓塞症风险评分 | vtescoreraw | 入院时静脉血栓栓塞症风险的来源评分；未填写时保持空缺 |
| 槽内措施项 | 措施名称 | measurenameraw | 该槽位下记录的防范措施原名，如使用约束带、腕带标识、渐进活动 |
| 槽内措施项 | 措施取值 | measurevalueraw | 该措施在这次评估中的取值，如是与否 |
| 槽内措施项 | 措施状态 | measure_status | 该措施的成立层级；措施状态与实施时间分列保存 |
| 槽内措施项 | 实施时间 | implementation_time | 该措施的实际实施时点；来源未记录时保持空缺 |
| 复评 | 效果判定状态 | causaleffectstatus | 措施与分数变化之间是否已作效果判定的声明 |
| 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，不在交付前静默修正 |
十八份入院护理评估。各带跌倒坠床、压力性损伤、疼痛、自理能力与静脉血栓栓塞症风险五类来源评分。「未涉及」等非数值取值与空缺项原样保留。十一条评估序列各按槽序展开五个评估槽位，共五十五个槽。其中四十个带有效总分，十五个为来源空值并注明缺失原因。槽内另挂一百三十四条来源措施项：使用约束带、腕带标识、渐进活动与其他措施。措施状态均为来源陈述，实施时间空缺。
{
"样例性质": "真实记录·已脱敏",
"nursing_series_candidate": [
{
"cross_file_linkage_status": "unresolved_masked_keys",
"series_id": "SERIES-0000001",
"series_status": "source_row_slot_candidate"
},
{
"cross_file_linkage_status": "unresolved_masked_keys",
"series_id": "SERIES-0000002",
"series_status": "source_row_slot_candidate"
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医疗科技企业 · 护理智能产品团队
获得：缺失、非数值与措施状态都分层清楚的护理量表训练样本
三甲医院 · 护理部质量管理
获得：可定位到具体复评次序的护理记录节律与齐套性核查口径
医院信息科与护理信息化企业
获得：覆盖宽表展开、空值与取值域异常的护理模块回归用例
医疗保险与护理服务评价机构
获得：风险分层与措施记录可对照、分母口径明确的护理服务评价底表
护理评估—干预—复评数据包含哪些内容？
护理评估—干预—复评数据（SHP-MED-04-029）组织一次护理服务过程的评估与再评估记录，含入院护理评估基线、按槽序展开的专项复评序列与同槽位的来源措施项。跌倒、压力性损伤、疼痛、自理能力与静脉血栓五类评分并列保存。
护理评估—干预—复评数据适合做什么？
适合护理量表结构化模型训练：宽表转长表、空值与缺失原因分档、「未涉及」等非数值取值处理都有真实样本；也适合高危患者复评节律与措施记录的核查、护理信息系统迁移的回归用例构造，以及风险分层与防范投入的服务评价研究。
护理评估—干预—复评数据有样例吗？怎么交付？
产品页提供真实脱敏样例：十八份入院护理评估与十一条评估序列，按槽序展开五十五个评估槽位，槽内另挂使用约束带、腕带标识等来源措施项，空值注明缺失原因。交付形态含数据集、API 调用、Token 计量与可信数据空间连接器。
护理评估—干预—复评数据如何定制与起步？
可选专项复评序列或入院护理评估基线，再按评估量表类型、复评次数、科室类别、医院等级与评估时间范围筛选，起订量为 1,000 份护理评估，数据量按项目商定。可先申请开源子集或测试数据，验证槽位展开与量表码表后再定制。
护理评估—干预—复评数据与哪些产品搭配使用？
常与风险评估与不良事件数据（SHP-MED-04-030）组合延伸到安全事件侧，与ICU监护与干预数据（SHP-MED-04-028）补齐重症护理的连续观察与干预记录，与住院诊疗数据（SHP-MED-01-002）拼出承载整段护理过程的住院背景。
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