临床文书上的时间表达与事件时序标注层。时间表达候选按字符偏移定位，各配一条临床事件候选与一条时序关系。每份文书带一个记录时间锚点，供相对时间换算。每条候选带发布类别、规范化状态与复核状态。可用于时间表达识别与时序关系模型训练、院内时间线规则设计与抽取引擎回归测试。
临床文本与标准化 · 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 | 6 | 标注文书 · 时间锚点 · 时间表达候选 · 临床事件候选 · 时序关系 · 数据质量项 |
| 字段 | 53 | 交付范围内的字段总数 |
| 实体关系 | 1 | 时间表达候选绑定它所在的文书与解析用的时间锚点。临床事件候选绑定其时间表达候选。时序关系把事件、候选与锚点三者连起来 |
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 |
|---|---|---|---|
| 时间锚点 | anchor_id | ||
| 时间锚点 | document_id | 文书标识 | |
| 时间锚点 | anchor_type | ||
| 时间锚点 | anchor_value | ||
| 时间锚点 | anchor_status | 锚点状态 | |
| 时间锚点 | data_nature | 数据性质 | |
| 标注文书 | document_id | 文书标识 | |
| 标注文书 | sourcedocumentkey | 来源文书键 | |
| 标注文书 | sourcerecordlocator | 来源记录定位 | |
| 标注文书 | content_sha256 | 正文校验值 | |
| 标注文书 | text_version | 文本版本 | |
| 标注文书 | scan_field | ||
| 标注文书 | scan_construction | ||
| 标注文书 | recordedtimeraw | 记录时间 | |
| 标注文书 | recordedtimemissing_reason | 记录时间缺失原因 | |
| 标注文书 | data_nature | 数据性质 | |
| 临床事件提及 | event_id | 事件标识 | |
| 临床事件提及 | candidate_id | 候选标识 | |
| 临床事件提及 | document_id | 文书标识 | |
| 临床事件提及 | event_status | 事件状态 | |
| 临床事件提及 | event_type | 事件类型 | |
| 临床事件提及 | review_status | 复核状态 | |
| 临床事件提及 | data_nature | 数据性质 | |
| 数据质量项 | qualityissueid | 数据质量项标识 | |
| 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 | affectedobjecttype | 受影响对象类型 | |
| 数据质量项 | affectedobjectid | ||
| 数据质量项 | data_nature | 数据性质 | |
| 时序关系 | relation_id | 关系标识 | |
| 时序关系 | left_id | ||
| 时序关系 | right_id | ||
| 时序关系 | anchor_id | ||
| 时序关系 | relation_type | 关系类型 | |
| 时序关系 | evidence_status | 证据状态 | |
| 时序关系 | data_nature | 数据性质 | |
| 时间表达候选 | candidate_id | 候选标识 | |
| 时间表达候选 | document_id | 文书标识 | |
| 时间表达候选 | sourcecandidatekey | ||
| 时间表达候选 | sourcedocumentkey | 来源文书键 | |
| 时间表达候选 | sourcecontentsha256 | ||
| 时间表达候选 | text_version | 文本版本 | |
| 时间表达候选 | rule_version | ||
| 时间表达候选 | textspanhash | ||
| 时间表达候选 | start_offset | 起始偏移 | |
| 时间表达候选 | end_offset | 结束偏移 | |
| 时间表达候选 | candidate_type | 候选类型 | |
| 时间表达候选 | publication_class | ||
| 时间表达候选 | normalized_value | ||
| 时间表达候选 | normalization_status | 规范化状态 | |
| 时间表达候选 | anchor_id | ||
| 时间表达候选 | review_status | 复核状态 | |
| 时间表达候选 | data_nature | 数据性质 |
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。
文本版本／记录时间
锚点取值／可用状态
类别／偏移／规范化状态
事件状态／复核状态
左右两端／证据状态
落到具体条目
每条关系独占一行，基数置于两实体之间
标注文书
文本版本／记录时间
时间锚点
锚点取值／可用状态
标注文书
文本版本／记录时间
时间表达候选
类别／偏移／规范化状态
时间表达候选
类别／偏移／规范化状态
临床事件候选
事件状态／复核状态
临床事件候选
事件状态／复核状态
时序关系
左右两端／证据状态
时间表达候选
类别／偏移／规范化状态
时序关系
左右两端／证据状态
时间锚点
锚点取值／可用状态
时序关系
左右两端／证据状态
时间表达候选
类别／偏移／规范化状态
数据质量项
落到具体条目
| 起 | 基数 | 至 | 关系语义 |
|---|---|---|---|
| 标注文书 | 1—1 | 时间锚点 | 一份文书带一个记录时间锚点，来源缺时锚值留空 |
| 标注文书 | 1—n | 时间表达候选 | 文本上按字符偏移定位的时间表达候选 |
| 时间表达候选 | 1—1 | 临床事件候选 | 时间候选与事件候选成对，事件不脱离它的时间线索 |
| 临床事件候选 | 1—n | 时序关系 | 事件侧接入时序关系 |
| 时间表达候选 | 1—n | 时序关系 | 时间侧接入时序关系 |
| 时间锚点 | 1—n | 时序关系 | 关系上记下解析时所用的锚点 |
| 时间表达候选 | 1—n | 数据质量项 | 按受影响对象类型与标识落到具体条目的问题登记 |
一份文书带一个记录时间锚点。文本上的时间表达候选按字符偏移定位，事件候选与时间候选成对。时序关系再把事件侧与时间侧连起来，并记下解析时所用的锚。问题登记落到受影响的那一条对象上。候选层与复核层在结构上分开，规范化取值在复核前一律留空。
| 分组 | 字段 | 英文键 | 语义 |
|---|---|---|---|
| 标注文书 | 记录时间 | recordedtimeraw | 来源系统登记该文书的时点，按来源取值保留；本例二十六份中二十二份有记录时间，四份来源未提供 |
| 标注文书 | 记录时间缺失原因 | recordedtimemissing_reason | 记录时间为空的原因，本例四份标为来源未提供；「取值为空」与「本来就没有这个时点」分开表达 |
| 时间锚点 | 锚点类型 | anchor_type | 这个锚出自何处，本例为文书记录时间；相对时间表达要落成具体时点，必须先有一个明确的锚 |
| 时间锚点 | 锚点取值 | anchor_value | 锚点的时点取值；来源缺记录时间的文书锚值留空，不借用相邻文书的时间顶替 |
| 时间锚点 | 锚点状态 | anchor_status | 该锚可用到什么程度，本例分为「来源值·非事件时间」与「来源值缺失」两种 |
| 时间表达候选 | 候选类型 | candidate_type | 该候选的时间性质，本例含绝对时间候选一百四十五个、相对时间候选五十九个、词法假阳性三个 |
| 时间表达候选 | 发布类别 | publication_class | 该候选对外交付时的归类；词法假阳性单独归类并被挡在时间语义层之外，不参与后续时间计算 |
| 时间表达候选 | 起始偏移与结束偏移 | startoffset／endoffset | 该候选在文书文本中的字符区间，按区间截取即得被命中的那段词面 |
| 时间表达候选 | 规则版本 | rule_version | 产生这批候选的抽取规则版本；同一文本配同一规则版本重跑，得到的是同一批候选与同一批偏移 |
| 时间表达候选 | 规范化取值 | normalized_value | 该时间表达换算出的标准时点或区间；未经复核时留空，不按书写体例常识补出年月日 |
| 时间表达候选 | 规范化状态 | normalization_status | 规范化推进到哪一步，本例全部为候选未复核；候选层与已复核层在交付结构上就是分开的 |
| 时间表达候选 | 复核状态 | review_status | 该条候选的处理状态，本例二百零四条待复核、三条已作为词法假阳性隔离 |
| 临床事件候选 | 事件状态 | event_status | 该事件是否已确认，本例全部停在候选未确认；规则命中不因进入交付包而变成已确认事件 |
| 临床事件候选 | 所依附的时间候选 | candidate_id | 该事件候选所依附的时间表达候选，使事件与给出它时间线索的那段词面成对 |
| 时序关系 | 关系类型 | relation_type | 事件与时间之间关系的类别，本例为候选时间关联；先后与包含这类判定须经复核后另行标注 |
| 时序关系 | 左端与右端 | leftid／rightid | 关系两端各指向哪一条对象，本例左端为事件候选、右端为时间表达候选，方向不合并 |
| 时序关系 | 证据状态 | evidence_status | 这条关系的证据来源与成熟程度，本例为规则产生、尚未复核 |
| 数据质量项 | 问题代码 | issue_code | 本批登记的两项：一是「现患者」一词被时间规则命中形成的词法假阳性，二是全部时间候选尚未复核 |
| 数据质量项 | 受影响对象类型与标识 | affectedobjecttype／affectedobjectid | 该问题落在哪一类对象的哪一条上，使问题可定位到具体条目 |
二十六份临床文书上抽出的二百零七个时间表达候选。每条给出所属文书、在文书文本中的字符起止区间、候选类别与复核状态。候选类别含绝对时间一百四十五个、相对时间五十九个、词法假阳性三个。另给出供相对时间换算用的文书记录时间锚点，二十六个锚点中二十二个有取值、四个来源未提供。每个候选各配一条临床事件候选与一条时序关系，三者一一对应。本产品交付脱敏后的文书文本与其上的标注层：字符起止区间、候选类别、时序关系与抽取规则版本。文本版本与抽取规则版本固定，同一文本按同一规则版本重跑得到同一批候选与同一批偏移。二百零七条候选的规范化取值在复核前一律留空，不按书写体例常识补出年月日。三条被时间规则命中的词法假阳性单独归类，不参与后续时间计算。
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"annotation_document": [
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"scan_field": "fallback_source_fields",
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"document_text": "2026-07-14 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2026-07-14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_text": "2026-07-15 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 :2026-07-14 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、2026-07-14 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_text": "2026-07-16 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:2026-07-16 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。2026-07-16 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_text": "2026-07-17 09:12 转出记录\n患者A，女，80岁，因便血1天于2026-07-14入院。\n入院科室：肛肠科，转出日期：2026-07-17 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2026-07-14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，2026-07-14 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、2026-07-14 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。2026-07-16 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。2026-07-16 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_text": "2026-07-17 10:40 转入记录\n患者A，女，80岁，因“便血1天”于2026-07-14入院。\n入院科室：肛肠科，转入日期：2026-07-17 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2026-07-14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，2026-07-14 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、2026-07-14 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。2026-07-16 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。2026-07-16 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_text": "2026-07-18 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2026-07-14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 :2026-07-14 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、2026-07-14 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。2026-07-16 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。2026-07-16 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_text": "2026-07-19 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2026-07-14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:2026-07-14 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、2026-07-14 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。2026-07-16 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。2026-07-16 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_text": "2026-07-19 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：2026-07-14 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。2026-07-14 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。2026-07-15 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。2026-07-16 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。2026-07-16 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。2026-07-17 常规心电图+十二通道加收,1.窦性心律；2.T波改变。2026-07-18 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（-）。2026-07-18 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_text": "2026-07-19 16:35 术前讨论记录\n讨论日期：2026-07-19 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2026-07-14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 :2026-07-14 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。2026-07-14 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。2026-07-15 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。2026-07-16 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。2026-07-16 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。2026-07-17 常规心电图+十二通道加收,1.窦性心律；2.T波改变。2026-07-18 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（-）。2026-07-18 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。2026-07-14 血常规:大型血小板比率 50.3(%)↑，平均血小板体积 13.6(fL)↑；2026-07-14 凝血功能:活化部分凝血活酶时间 23.3(sec)↓；2026-07-14 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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"document_text": "2026-07-19 17:17 术前小结\n 患者患者A，女性，80岁，因“便血1天”于2026-07-14入院。\n目前诊断为：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诊断依据：结合患者主诉、病史、查体及辅助检查可诊断。\n拟行手术：腹腔镜直肠癌根治术。\n拟行手术部位：直肠。\n手术时间：2026-07-20。\n手术人员：医生L、医生C、规培医师。\n拟行麻醉方式：全麻。\n手术禁忌症： 目前已经完善术前相关检查，未见明显手术禁忌症。 \n1.放射影像类异常检查结果: 2026-07-16 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。2026-07-18 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（-）。2026-07-18 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。 \n2.超声类异常检查结果: 2026-07-14 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。2026-07-14 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。 \n3.病理检查结果： 2026-07-15 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。2026-07-16 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。 \n4.心脏电生理类检查结果： 2026-07-17 常规心电图+十二通道加收,1.窦性心律；2.T波改变。 \n5.凝血功能结果: 2026-07-14 凝血功能:活化部分凝血活酶时间 23.3(sec)↓； \n6.其他异常辅检结果: 2026-07-14 血常规:大型血小板比率 50.3(%)↑，平均血小板体积 13.6(fL)↑；2026-07-14 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)↑。 \n7.术前是否使用抗凝药物：否 桥接方案: - \n8.65岁以上患者术前智力评估结果：2至3分无失智 术前是否已确诊认知障碍:否\n以上8条禁忌症相关内容，请认真填写，上级认真审核，应填未填，单否乙级。\n手术指征：患者的病史、临床表现、检验、影像及病理检查等支持诊断。\n注意事项：1、出血--术中注意止血；2、感染--注意无菌操作；3、损伤邻近组织--仔细操作与保护；4、切除临近器官--与家属沟通；5、病变无法切除--与家属沟通。\n手术要点：术中完整切除直肠癌，清扫周围淋巴结，术中注意保护输尿管、神经等，止血彻底。\n术前准备：术前完善更衣、备皮、禁食项目，术前拟使用头孢呋辛预防感染。目前检查患者能耐受手术，拟明日手术。\n术前手术者查看患者情况记录：\n今日查看患者，精神、饮食、睡眠可，无咳嗽咳痰，无畏寒发热，无胸闷气喘心悸等特殊不适，大小便可。查体：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。目前术前检查完善，无明显手术禁忌症，有手术指针，按计划明日手术，积极术前准备。\n医师签名：医生L/医生C\n"
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"document_text": "2026-07-20 15:55 术后首次病程记录\n 患者于今日在全身麻醉下行腹腔镜下直肠前切除术+回肠预防性单腔造口术。术中见:腹腔清亮腹水约50ml，腹膜、肝脏表面光滑无结节，肝胆脾胃结肠未见明显异常。小肠部分粘连，直肠中下段质硬包块，侵及肌层，边界不清，较固定，直径3cm*2cm*2cm。肠系膜下动脉根部，乙状结肠系膜见多个肿大淋巴结。手术简要经过：1.全麻成功后，取截石位，常规消毒铺巾，取脐上1.2cm小切口置入1.2cmTroca建立气腹和观察孔，取左下腹及耻骨上各置入0.5cmTroca建立辅助操作孔、取右下腹及耻骨上小切口分别置入1.2cm及0.5cmTroca建立主操作孔，术中所见如上述。2.消融电极解剖器松解粘连小肠，超声刀打开乙状结肠及直肠系膜，松解左侧粘连输尿管并注意保护，游离肠系膜下动脉及静脉，游离并保留左结肠动脉，清扫其周围淋巴结送病检，于肠系膜下动脉及静脉远端用塑料夹夹闭后切断，遇到较大血管使用塑料夹夹闭。超声刀游离乙状结肠及直肠至包块远端3cm，于包块远端2cm处用切割闭合器及2个闭合钉闭合并切断。静脉注射吲哚菁绿帮助术中显示边缘血管血供，判断近端肠管切除位置，切割闭合器及2个闭合钉闭闭合并切断，撤除气腹。3.经下腹切口，逐层进腹，安置切口保护套，移出标本。近端肠管断端置入26#吻合器头，丝线固定。放回腹腔，重新建立气腹，于肛门放吻合器，近远端行结肠-直肠端端吻合。安置盆腔及肛门引流管。4.经右下腹环形切口直径约2.5cm逐层进腹，距回盲部约20cm拖出回肠，使用切割闭合器及1个闭合钉切断回肠，近端回肠分层固定于前鞘及皮下，术中开放，丝线固定肠壁于皮下。5.查无活动性出血，清点纱布器械无误，缝合各穿刺孔，手术顺利，术中满意，术后患者送PACU复苏观察。术后诊断：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。术后处理：予以禁食禁水、心电监测、吸氧、血氧饱和度监测、监测血糖、伤口换药等对症处理，予以头孢呋辛钠预防性抗感染、吸入用布地奈德混悬液雾化、氨茶碱解痉、盐酸氨溴索化痰、琥珀酰明胶注射液扩容、血凝酶止血、法莫替丁抑酸、营养支持等对症治疗。予以红蓝激光促进伤口愈合、双下肢气压治疗预防深静脉血栓、低频脉冲电治疗治疗老年患者术后排尿困难、排痰机辅助排痰，密切关注引流情况及病情变化。\n医师签名：医生C\n"
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"document_text": "2026-07-21 07:43 中医治疗协作会诊申请\n 协作会诊申请时间：2026-07-21 07:43\n一般病史及诊疗经过： \n会诊治疗项目：中药热熨敷技术，穴位敷贴技术。 \n协作会诊申请目的：请中医及中西医结合科协作、指导治疗。\n医师签名：医生C\n\n\n"
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"document_text": "2026-07-21 09:09 医生C职称B查房记录\n今日医生C职称B查房：患者神清，精神稍差，自诉手术切口疼痛不适，轻微咳嗽咳痰，轻微恶心反酸烧心不适，偶有干呕，偶有轻微胸闷气促不适，无畏寒发热，小便可，造口少许未排气排便。查体：生命体征平稳，心脏未见明显异常，双肺呼吸音粗，未闻及明显干湿啰音，腹部轻微压痛、无明显反跳痛及肌紧张，切口敷料少许渗出。引流管通畅，引出少量鲜红色血性液体；尿管通畅，尿量可，颜色正常。双下肢无水肿。造瘘口处肠粘膜红润、水肿，造瘘袋中少许气体及粪水溢出。查房指示：目前患者病重，生命体征较平稳，继续吸氧，一级护理及心电监护。目前予以头孢呋辛钠预防抗感染、氨茶碱扩张支气管、氨溴索祛痰、布地奈德雾化、氟比洛芬酯止痛、恩丹西酮止吐、脂肪乳氨基酸(17)葡萄糖(11%)注射液(1440ml/袋)加强营养支持、艾普拉唑钠抑酸预防应激性溃疡出血、补充微量元素及维生素、矛头蝮蛇血凝酶止血、输白蛋白纠正低蛋白症状等对症治疗，维持水电解质平衡。患者术后VTE评估为高危，出血高风险，目前无静脉血栓相关表现，药物抗凝可能加重术后出血，目前暂时给予双下肢、双足气压物理治疗防止下肢血栓形成，必要时可行血管彩超检查、药物抗凝治疗。给予切口激光治疗，每日换药观察切口情况，机械辅助排痰，嘱患者主动咳嗽及适当活动，翻身排背。观察四肢血循环。低频脉冲电治疗促进膀胱功能恢复，功能性电刺激促进胃肠功能恢复。加强造口护理、会阴护理、口腔护理、引流管护理，避免引流管滑脱，保持敷料清洁干燥。指导小茴香热敷，促进胃肠功能恢复，复查血常规及生化等检测，控制血压、血糖水平，密切观察病情变化。\n医师签名：医生C\n"
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"document_text": "2026-07-21 11:57 中医治疗协作会诊记录\n会诊意见：病史敬悉，结合患者病史及查体，有中医技术治疗指征，建议使用以下治疗技术:中药热熨敷技术，穴位敷贴技术. \n穴位敷贴：可用吴茱萸、党参、佛手贴：天枢、中脘、脾俞、胃俞、大肠俞、气海、关元、足三里等。我科随诊，谢邀。\n中药热熨敷：予以小茴香加热外敷腹部行气止痛对症。\n医师签名：医生AQ\n"
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"document_text": "2026-07-21 17:12 日常病程记录\n 术后第一天，今日查房，患者神清，精神可，自诉手术切口疼痛不适有所好转，轻微咳嗽咳痰，反酸烧心恶心不适有所好转，偶有干呕，无明显畏寒发热，偶有轻微胸闷气紧不适，小便可，造口少许排气排便。查体情况：生命体征平稳，心脏未见明显异常，双肺呼吸音粗，未闻及明显干湿啰音，腹部轻微压痛、无明显反跳痛及肌紧张，切口少许渗出。引流管通畅，引出少量鲜红色血性液体；尿管通畅，尿量可，颜色正常。造瘘口处肠粘膜红润、水肿，造瘘袋中少许气体及粪水溢出。辅助检查情况：2026-07-21 生化全套+肌酶Ⅰ:总蛋白 47.3(g/L)↓，白蛋白 27.3(g/L)↓，总胆红素 34.8(umol/L)↑，直接胆红素 7.5(umol/L)↑，间接胆红素 27.3(umol/L)↑，总钙 2.01(mmol/L)↓，镁 0.69(mmol/L)↓，氯 111.2(mmol/L)↑；2026-07-21 血常规+全血超敏C反应蛋白:【白细胞计数】 7.0(10^9/L)，中性粒细胞比率 77.8(%)↑，血红蛋白 97(g/L)↓，超敏C反应蛋白 36.02(mg/L)↑；2026-07-21 脑钠肽:B型钠尿肽 210.2(pg/mL)↑；2026-07-21 降钙素原+心肌损伤三合一:降钙素原 0.14(ng/mL)↑；诊疗计划：遵上级医师指示执行，嘱其适度咳嗽咳痰、适当活动，密切观察病情变化。\n医师签名：医生C\n"
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"document_text": "2026-07-22 09:14 日常病程记录\n 术后第二天，患者自诉手术切口疼痛不适有所好转，咳嗽咳痰明显好转，轻微反酸烧心恶心，偶有干呕，无畏寒发热，偶有轻微胸闷气紧不适，小便可，造口少许排气排便。查体情况：生命体征平稳，神志清楚，精神可，双肺呼吸音粗，未闻及明显干湿罗音，心脏查体未见异常，腹软，腹部轻微压痛、无明显反跳痛及肌紧张，手术切口敷料少许渗出，双下肢无明显水肿。引流管通畅，引出少量鲜红色血性液体；尿管通畅，尿量可，颜色正常。造瘘口处肠粘膜红润、水肿，造瘘袋中少许气体及粪水溢出。辅助检查情况：暂无新增。诊疗计划：继续目前治疗方案，密切观察病情变化。\n医师签名：医生C\n"
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"document_text": "2026-07-26 08:53 医生H职称C查房记录\n 今日医生H职称C查房：患者精神、睡眠可，诉轻微手术切口疼痛不适，偶有轻微阵发性腹胀腹痛不适，偶有轻微反酸烧心，无恶心呕吐，轻微咳嗽咳痰，偶有轻微胸闷气促，无胸痛心悸不适，大便次数稍增多，稀便，小便正常。查体：心脏未见明显异常，双肺呼吸音粗，未闻及干湿啰音。腹部软，无明显压痛、反跳痛及肌紧张，腹部切口敷料整洁干燥，伤口皮肤轻微发红，少许渗出，无波动感。引流管通畅，少量淡血性液体引出。造瘘口通畅，黏膜红润，水肿减轻，无坏死及狭窄。2026-07-25 胸部CT薄层平扫,上腹部CT薄层平扫（空腹）,盆腔CT薄层平扫（适度胀尿）,CT薄层平扫（加收）,较2026-07-17胸部片1、双肺散在纤维灶，新增双肺下叶少许炎性病变、胸膜下部分肺膨胀不全。2、右肺下叶背段小结节，LU-RADS 2类，较前相似。3、冠状动脉及主动脉钙化。4、双侧胸膜稍增厚，新增双侧胸腔少量积液。5、扫及甲状腺右侧叶低密度结节，请结合超声检查。较2026-07-16腹部片6、新增直肠术后改变，术区高密度影，盆腔筋膜增厚肿胀，盆腔少量积液，右下腹造瘘后改变，盆腔引流后改变，随诊。7、老年性子宫改变，膀胱未见异常。8、胆囊多发结石并慢性胆囊炎，较前相似。9、肝内外胆管稍扩张。10、胰腺、脾脏平扫未见明显异常。11、附及：右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿可能。2026-07-25 生化全套+肌酶Ⅰ:总蛋白 56.1(g/L)↓，白蛋白 34.5(g/L)↓，血清铁 4.0(umol/L)↓，肌酸激酶 31(U/L)↓，乳酸脱氢酶 105(U/L)↓；2026-07-25 血常规+全血超敏C反应蛋白:血红蛋白 100(g/L)↓，超敏C反应蛋白 42.14(mg/L)↑；2026-07-22 一般细菌涂片:鳞状上皮细胞>25个/LP,WBC <10个/LP ，未找到细菌；2026-07-24 细菌培养:正常菌群生长。诊疗计划：继续给予扩管、止咳、祛痰、雾化、营养支持等对症治疗，患者目前病情较稳定，已排气排便，嘱其开始流质饮食，逐步加强营养摄入。给予洛索洛芬钠止痛，铝镁加护胃，四逆散、复方谷氨酰胺促胃肠功能恢复等对症治疗。必要时复查腹腔彩超，若无明显积液，可拔出引流管。患者VTE评估高危，嘱其适度下床活动防止血栓。给予每天伤口换药，注意查看伤口有无感染、液化情况，必要时伤口间断拆线引流。密切观察病情变化，遵指示执行。\n医师签名：医生H/医生C\n"
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"document_text": "{\"手术开始时间\": \"2026-07-20T09:00:00\", \"手术结束时间\": \"2026-07-20T11:50:00\", \"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2026-07-20 09:00 2026-07-20 11:50\", \"术后诊断\": \"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\", \"手术名称\": \"腹腔镜下直肠前切除术+回肠预防性单腔造口术\", \"麻醉方法\": \"全身麻醉\", \"手术经过\": \"1.全麻成功后，取截石位，常规消毒铺巾，取脐上1.2cm小切口置入1.2cmTroca建立气腹和观察孔，取左下腹及耻骨上各置入0.5cmTroca建立辅助操作孔、取右下腹及耻骨上小切口分别置入1.2cm及0.5cmTroca建立主操作孔，术中所见如上述。2.消融电极解剖器松解粘连小肠，超声刀打开乙状结肠及直肠系膜，松解左侧粘连输尿管并注意保护，游离肠系膜下动脉及静脉，游离并保留左结肠动脉，清扫其周围淋巴结送病检，于肠系膜下动脉及静脉远端用塑料夹夹闭后切断，遇到较大血管使用塑料夹夹闭。超声刀游离乙状结肠及直肠至包块远端3cm，于包块远端2cm处用切割闭合器及2个闭合钉闭合并切断。静脉注射吲哚菁绿帮助术中显示边缘血管血供，判断近端肠管切除位置，切割闭合器及2个闭合钉闭闭合并切断，撤除气腹。3.经下腹切口，逐层进腹，安置切口保护套，移出标本。近端肠管断端置入26#吻合器头，丝线固定。放回腹腔，重新建立气腹，于肛门放吻合器，近远端行结肠-直肠端端吻合。安置盆腔及肛门引流管。4.经右下腹环形切口直径约2.5cm逐层进腹，距回盲部约20cm拖出回肠，使用切割闭合器及1个闭合钉切断回肠，近端回肠分层固定于前鞘及皮下，术中开放，丝线固定肠壁于皮下。5.查无活动性出血，清点纱布器械无误，缝合各穿刺孔，手术顺利，术中满意，术毕病员送PACU。\"}"
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医疗科技企业 · 临床时间信息抽取团队
获得：正例、难例与拒识样本齐备的时间表达训练输入
三甲医院 · 临床研究中心时间线建设
获得：动手抽时间线之前就能判明的时间语义分布与锚点可用性
医疗信息化企业 · 文本抽取引擎研发
获得：可逐条复算、可跨版本比对的抽取规则基线
医学数据加工团队 · 标注工作流组织
获得：条目化、可分派、工作量可估算的时间标注复核队列
临床时间事件标注数据包含哪些内容？
临床时间事件标注数据（SHP-MED-05-033）交付临床文书上的时间表达与事件时序标注层：时间表达候选按字符偏移定位，分绝对时间、相对时间与词法假阳性三类，各配一条临床事件候选与一条时序关系，每份文书带记录时间锚点供相对时间换算。
临床时间事件标注数据适合做什么？
适合时间表达识别与时序关系模型训练，被时间规则误命中的词面可直接作拒识样本；也适合院内病历时间线规则设计前的时间语义盘点、抽取引擎的跨版本回归对照，以及时间标注复核队列的组织与工作量估算。
临床时间事件标注数据有样例吗？怎么交付？
产品页提供真实脱敏样例：二十六份文书上抽出的二百零七个时间表达候选，含绝对时间、相对时间与词法假阳性三类，配套记录时间锚点与时序关系，文本与规则版本固定、结果可复算。交付形态含数据集、API 调用、Token 计量与可信数据空间连接器。
临床时间事件标注数据如何定制与起步？
交付层次可选只交付候选层，或候选层加人工复核结果，再按时间表达类型、文书类型、相对时间锚点策略、事件类型与文书时间范围定制，起订量为 10,000 条时间表达候选，数据量按项目商定。可先申请开源子集或测试数据熟悉候选结构。
临床时间事件标注数据与哪些产品搭配使用？
常与临床文书分类与章节切分数据（SHP-MED-05-031）取得被扫描文书的版本与章节坐标，与临床实体与关系标注数据（SHP-MED-05-032）叠加同一批文本的实体与关系标注层，与纵向病程与时间推理评测集（SHP-MED-07-043）衔接时间能力的成题评测。
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