D004 临床文档结构整理

识别入院记录、病程、出院小结及其他临床文档，整理主诉、现病史、检查和诊疗经过等章节，保留原文位置与来源。

个人 Skill知识加工15 个文件浏览次数 2

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输入资料: Required: D003 deidentified_manifest.json Recommended: D003 phi_gate_report.json explicit privacy review decisions for any sanitized_review_required source that should become model-readable Preferred invocation:Privacy r… 阅读本节完整说明
交付内容: Always produce when any supported document surfaces are found: document_structure_manifest.json — text-free handoff manifest document_structure_report.md — aggregate report only document_section_inventory.csv — text-free… 阅读本节完整说明

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阅读对应使用步骤与输入输出说明，在自己的环境中验证结果。

使用提示摘自原文，配套文件保留来源版本；实际运行条件以各包说明为准。

正文

获取原文件

references/chinese-clinical-section-ontology.md

D004 uses a conservative alias dictionary rather than free-form semantic guessing.

The canonical labels are intentionally cross-document and machine-oriented. Chinese and English headings map into the same label, e.g.:

主诉 / Chief Complaint → chief_complaint
现病史 / HPI → history_present_illness
既往史 / PMH → past_medical_history
入院诊断 → admission_diagnosis
诊疗经过 / Hospital Course → progress_course
出院诊断 → discharge_diagnosis
出院医嘱 → discharge_instructions
影像所见 / Findings → radiology_findings
印象 / Impression → radiology_impression

Conservative behavior

D004 recognizes headings only when they look like headings:

an alias followed by : / ：, or
an alias occupying a line by itself (allowing surrounding whitespace)

The same word appearing inside ordinary prose is not treated as a heading merely because it matches an alias.

Unknown local headings are preserved in unstructured/front-matter spans and should be added to the ontology only after examples are reviewed.