诊断和手术画像Schema规范¶
说明¶
场景说明¶
诊断和手术画像的输出结果, 用于平台展示。
格式说明¶
schema主要包含六个个一级字段信息: - 诊断信息: 该字段为**单据来源**维度（入院记录、病程记录等)下的诊断集合，每个单据列举了其所有诊断。该字段**包含既往史疾病**在内的全部诊断信息； - 诊断变化: 该字段为**诊断**维度下的诊断集合，包含患者住院期间的疾病诊断（不包含既往史疾病）； - 入院诊断和出院诊断: 该字段包含入院记录中的诊断集合(不包含既往疾病)和出院记录中的诊断全集，作为诊断集合变化的参照； - 手术及操作信息：该字段为**单据来源** 维度（入院记录、手术记录等）下的手术及操作集合，每个单据列举了其所有手术及操作。该字段**包含既往史手术**在内的全部手术操作信息； - 手术及操作变化: 该字段为**手术及操作**维度下的手术及操作集合，包含患者住院期间相关的手术和手术操作（不包含既往史手术）； - 出院手术及操作: 包含出院记录中的手术及操作集合，作为集合变化的参照。
其中，诊断类型包括: 既往诊断/新增诊断/修正诊断/消失诊断。手术及操作状态包括：既往/拟行/执行/取消/未来规划。
诊断和手术画像输出示例¶
ICD结构¶
ICD字段结构如下，当医学术语与医保版术语完全匹配时返回唯一比配结果，当不完全匹配时返回top3匹配结果。 为节省篇幅，画像示例中的ICD省略为[]。
[
{
"name":"哮喘",
"code":{
"标准版":"J45.900",
"临床版":"J45.900",
"医保版":"J45.900"
},
"shuyu":{
"标准版":"哮喘",
"临床版":"哮喘",
"医保版":"哮喘"
},
"score":1
}
]
画像输出示例¶
{
"诊断信息":[
{
"source": "既往史",
"content": [
{
"time" : "2018-09-12 12:00:00",
"item": [
{
"name": "哮喘",
"field-source":"入院记录-既往史",
"ICD":[
{
"name":"哮喘",
"code":{
"标准版":"J45.900",
"临床版":"J45.900",
"医保版":"J45.900"
},
"shuyu":{
"标准版":"哮喘",
"临床版":"哮喘",
"医保版":"哮喘"
},
"score":1
}
],
"type": "既往诊断"
},
{
"name":"肺炎",
"field-source":"入院记录-个人史",
"ICD": [],
"type": "既往诊断"
}
]
},
{
"item": [
{
"name": "肺癌",
"field-source":"入院记录-既往史",
"ICD": [],
"type": "既往诊断"
}
],
"time": "2009-02-27 12:00:00"
}
]
},
{
"source": "入院记录",
"content": [
{
"item":[
{
"name": "伤寒",
"field-source":"入院记录-主诉",
"ICD": [],
"type": "新增诊断"
},
{
"name": "哮喘",
"field-source":"入院记录-诊断",
"ICD": [],
"type": "新增诊断"
}
],
"time": "2020-09-12 12:00:00"
}
]
},
{
"source": "出院记录",
"content": [
{
"item":[
{
"name": "中度伤寒",
"field-source":"出院记录-诊断",
"ICD": [],
"type": "新增诊断"
},
{
"name": "哮喘",
"field-source":"出院记录-诊断",
"ICD": [],
"type": "新增诊断"
},
{
"name": "脑炎",
"field-source":"出院记录-诊断",
"ICD": [],
"type": "新增诊断"
}
],
"time": "2020-09-15 12:00:00"
}
]
}
],
"诊断变化": [
{
"name":"伤寒",
"ICD": [],
"type": "新增诊断",
"path":[
{
"source": "入院记录",
"time":["2020-09-12 12:00:00"]
},
{
"source": "日常病程记录",
"time":["2020-09-14 12:00:00"]
},
{
"source": "出院记录",
"time":["2020-09-20 12:00:00"]
}
]
},
{
"name": "脑膜炎",
"ICD": [],
"type": "新增诊断",
"path": [
{
"source": "日常病程记录",
"time":["2020-09-14 12:00:00"]
},
{
"source": "出院记录",
"time":["2020-09-20 12:00:00"]
}
]
}
],
"入院诊断和出院诊断": {
"入院":[
"伤寒",
"哮喘"
],
"出院":[
"中度伤寒",
"哮喘",
"脑炎"
]
},
"手术及操作信息": [
{
"source": "既往史",
"content": [
{
"time" : "2018-09-12 12:00:00",
"item": [
{
"name": "输尿管切除术",
"field-source":"入院记录-既往史",
"ICD":[
{
"name":"肾输尿管切除术",
"code":{
"标准版":"55.5100",
"临床版":"55.5100",
"医保版":"55.5100"
},
"shuyu":{
"标准版":"肾输尿管切除术",
"临床版":"肾输尿管切除术",
"医保版":"肾输尿管切除术"
},
"score":1
}
],
"type": "既往"
}
]
},
{
"item": [
{
"name": "胆囊切除术",
"field-source":"入院记录-既往史",
"ICD": [],
"type": "既往"
}
],
"time": "2009-02-27 12:00:00"
}
]
},
{
"source": "入院记录",
"content": [
{
"item":[
{
"name":"泪腺切除术",
"field-source":"入院记录-现病史",
"ICD": [],
"type": "拟行"
}
],
"time": "2020-09-12 12:00:00"
}
]
},
{
"source": "手术记录",
"content": [
{
"item":[
{
"name":"泪腺活组织检查",
"field-source":"手术记录-手术项目",
"ICD": [],
"type": "执行"
},
{
"name": "泪腺切除术",
"field-source":"手术记录-手术项目",
"ICD": [],
"type": "取消"
}
],
"time": "2020-09-13 12:00:00"
}
]
},
{
"source": "出院记录",
"content": [
{
"item":[
{
"name": "泪腺活组织检查",
"field-source":"出院记录-诊疗经过",
"ICD": [],
"type": "执行"
},
{
"name": "泪腺切除术",
"field-source":"出院记录-诊疗经过",
"ICD": [],
"type": "取消"
},
{
"name": "甲状腺全部切除术",
"field-source":"出院记录-出院医嘱",
"ICD": [],
"type": "未来规划"
}
],
"time": "2020-09-15 12:00:00"
}
]
}
],
"手术及操作变化": [
{
"name": "泪腺切除术",
"ICD": [],
"type":"取消",
"path": [
{
"source": "入院记录",
"time":["2020-09-12 12:00:00"],
"type": "拟行"
},
{
"source": "手术记录",
"time":["2020-09-16 12:00:00"],
"type": "取消"
}
]
},
{
"name": "泪腺活组织检查",
"ICD": [],
"type": "执行",
"path":[
{
"source": "日常病程记录",
"time":["2020-09-16 12:00:00"],
"type": "拟行"
},
{
"source": "手术记录",
"time":["2020-09-16 12:00:00"],
"type": "执行"
},
{
"source": "出院记录",
"time":["2020-09-20 12:00:00"],
"type": "执行"
}
]
},
{
"name": "甲状腺全部切除术",
"ICD": [],
"type": "未来规划",
"path": [
{
"source": "出院记录",
"time":["2020-09-20 12:00:00"],
"type": "未来规划"
}
]
}
],
"出院手术及操作": {
"出院":{
"泪腺切除术": "取消",
"甲状腺全部切除术": "未来规划",
"泪腺活组织检查": "执行"
}
}
}