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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正文

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references/document-structure-contract.md

D004 turns a de-identified narrative surface into a structure-preserving document object.

Required distinctions

Document classification answers what kind of document this appears to be.
Section segmentation answers where named document sections begin and end.
Clinical fact extraction is out of scope. D004 must not convert section text into diagnoses, symptoms, medications, labs, or procedures.

Offset contract

All offsets are zero-based Python character offsets into the exact full_text stored in the same StructuredDocument JSON.

For each section:

heading_start, heading_end delimit the detected heading span when a heading exists.
content_start, content_end delimit the exact content slice.
text == full_text[content_start:content_end].
Sections must not overlap.
Unknown/front matter is retained rather than discarded.

Section provenance

Every section carries:

source reference
document id
canonical section label
original heading label when present
detection method
confidence
offsets

This allows D005 to cite a clinical fact back to an exact section/span.

Review semantics

auto_structured means the deterministic structure is mechanically coherent; it does not mean clinically correct.

needs_review is required when, for example:

D003 marked the source sanitized_review_required and no approval exists
document type is unknown
no recognized section headings were found
only a small fraction of content is under recognized clinical sections
contradictory/ambiguous header structure is detected

blocked means D004 was not allowed to read/process the source.