discharge

Discharge Summary Management Skill

Save and structure discharge summary information. Supports extraction from images or direct processing from text descriptions.

Core Process

用户输入 → 识别来源类型 → [图片]读取分析图片 → 提取信息 → 生成JSON → 保存
                              ↓
                         [文字]解析文本 → 提取信息 → 生成JSON → 保存

Step 1: Parse User Input

Source Type Recognition

Input Pattern	Source Type
Starts with @, .jpg/.png	Image path
Contains "hospitalization", "discharge" keywords	Text description

Date Recognition

Admission date format:(\d{4}-\d{2}-\d{2}) or (\d{4}年\d{1,2}月\d{1,2}日)
Discharge date format: same as above

Step 2: Check Information Completeness

Required fields:

source - Source of discharge summary (image or text)

Strongly recommended (can be extracted from image/text):

basic_info.hospital - Hospital name
basic_info.admission_date - Admission date
basic_info.discharge_date - Discharge date
diagnosis.discharge_diagnosis.main - Primary diagnosis

Step 3: Image Analysis (Image Source)

Use mcp__4_5v_mcp__analyze_image tool to analyze the discharge summary image:

Image analysis prompt template:

请详细识别这张出院小结的所有内容，包括：

1. 基础信息：患者姓名、性别、年龄、入院日期、出院日期、住院天数、住院科室、床号、医保类型

2. 诊断信息：入院诊断（主要诊断和其他诊断）、出院诊断（主要诊断和其他诊断）、诊断编码（ICD-10，如有）

3. 治疗经过：
   - 主要治疗措施
   - 药物治疗：药品名称、剂量、用法用量、用药起止日期、药物类别、适应症
   - 输液治疗：输液名称、添加药物、剂量、频率、起止日期
   - 非药物治疗：物理治疗、氧疗、雾化等
   - 肿瘤治疗（如适用）：
     * 放疗：放射部位、总剂量、次数、放疗技术、起止日期
     * 化疗：方案名称、周期、药物、剂量、不良反应
     * 靶向治疗：药物名称、靶点、剂量
     * 免疫治疗：药物名称、类型、剂量
   - 手术记录（如有）：手术名称、日期、麻醉方式
   - 检查结果摘要

4. 治疗效果评估：总体疗效（显效/有效/好转/无效）、症状改善、不良反应、实验室指标改善

5. 出院情况：出院时病情状态、症状改善情况、生命体征

6. 出院医嘱：用药指导、饮食指导、活动指导、伤口护理（如有）、复查计划和时间、注意事项

7. 其他信息：主治医生、医院名称、住院费用（如有）、随诊电话

请以结构化的方式列出所有信息，保持原文准确性。

Step 4: Generate JSON

Discharge summary data structure

{
  "id": "2024081500001",
  "basic_info": {
    "hospital": "某某医院",
    "department": "消化内科",
    "admission_date": "2024-08-10",
    "discharge_date": "2024-08-15",
    "hospitalization_days": 5,
    "bed_number": "23床",
    "insurance_type": "职工医保"
  },
  "diagnosis": {
    "admission_diagnosis": {
      "main": "急性胆囊炎",
      "secondary": ["胆囊结石", "高血压病（2级，中危组）"]
    },
    "discharge_diagnosis": {
      "main": "急性胆囊炎",
      "secondary": ["胆囊结石", "高血压病（2级，中危组）", "2型糖尿病"]
    }
  },
  "treatment_summary": {
    "main_treatments": ["禁食水、胃肠减压", "抗感染治疗", "解痉止痛治疗"],
    "medications": [
      {
        "drug_name": "阿莫西林胶囊",
        "dosage": "0.5g",
        "frequency": "每日3次",
        "route": "口服",
        "duration": "7天",
        "start_date": "2024-08-10",
        "end_date": "2024-08-15",
        "drug_category": "抗生素",
        "indication": "抗感染",
        "notes": "饭后服用"
      }
    ],
    "infusion_therapy": [
      {
        "solution_name": "0.9%氯化钠注射液",
        "additives": ["头孢哌酮钠舒巴坦钠 2g"],
        "dosage": "100ml",
        "frequency": "每日2次",
        "route": "静脉滴注",
        "duration": "5天",
        "start_date": "2024-08-10",
        "end_date": "2024-08-15"
      }
    ],
    "non_drug_treatments": [
      {
        "treatment_type": "氧疗",
        "treatment_name": "低流量吸氧",
        "parameters": "2L/min，每日2次，每次30分钟",
        "duration": "3天",
        "start_date": "2024-08-10",
        "end_date": "2024-08-12"
      }
    ],
    "treatment_effectiveness": {
      "overall_effect": "显效",
      "symptom_improvement": "腹痛完全缓解，体温恢复正常，无恶心呕吐",
      "adverse_reactions": [],
      "lab_improvements": "白细胞计数由15.2×10^9/L降至7.8×10^9/L，CRP正常"
    },
    "surgeries": [
      {
        "surgery_name": "腹腔镜下胆囊切除术",
        "surgery_date": "2024-08-12",
        "anesthesia": "全身麻醉",
        "surgeon": "张医生"
      }
    ]
  },
  "discharge_status": {
    "condition": "好转",
    "symptoms": "腹痛缓解，无发热，饮食恢复",
    "vital_signs": {
      "blood_pressure": "130/80 mmHg",
      "heart_rate": "78 次/分",
      "temperature": "36.5℃"
    }
  },
  "discharge_orders": {
    "medication_instructions": [...],
    "dietary_guidance": "低脂饮食，少食多餐，避免油腻食物",
    "follow_up_plan": [
      {
        "item": "术后复查",
        "timing": "术后2周",
        "location": "普通外科门诊"
      }
    ],
    "warnings": ["如出现发热、腹痛、黄疸等症状，请及时就医"]
  }
}

Step 5: Save Data

If image, copy to data/discharge-summaries/YYYY-MM/images/
Create month directory (if not exists)
Save JSON data file: data/discharge-summaries/YYYY-MM/YYYY-MM-DD_main-diagnosis.json
Update global index data/index.json

Execution Instructions

1. 识别用户输入类型（图片或文字）
2. 图片来源：
   a. 使用 Read 工具读取图片
   b. 使用 mcp__4_5v_mcp__analyze_image 分析图片
   c. 提取结构化信息
3. 文字来源：
   a. 从文字中提取信息
   b. 按照数据结构分类
4. 如有缺失关键信息，询问用户补充
5. 生成 JSON 并保存

Intelligent Extraction Rules

Diagnosis Information Extraction

Primary diagnosis: usually the diagnosis listed first
Secondary diagnoses: comorbidities, complications
ICD-10 code: extract automatically if available

Surgical Information Extraction

Identify "surgery name", "surgery date", "anesthesia method"
Automatically link to the surgical record (if it already exists)

Medication Information Extraction

Drug name (generic name)
Dose (e.g., 0.5g, 10mg)
Usage (3 times daily, q8h, as needed)
Route of administration (oral, intravenous drip, intramuscular injection)
Course of treatment (7 days, follow doctor's advice)
Medication start and end dates (inferred from hospitalization records)
Drug category (antibiotics, antihypertensives, antidiabetics, analgesics, etc.)
Indication (what symptoms or diseases it is used to treat)

Infusion Therapy Extraction

Infusion name (0.9% sodium chloride, 5% glucose, etc.)
Added drugs (cefXX, potassium chloride, etc.)
Volume (100ml, 250ml, 500ml)
Frequency (once daily, q12h, q8h)
Start and end dates

Non-pharmacological Treatment Extraction

Treatment type (physical therapy, traditional Chinese medicine treatment, oxygen therapy, nebulization, dialysis, etc.)
Specific name and parameters
Treatment frequency and number of days

Treatment Efficacy Extraction

Overall efficacy (markedly effective/effective/improved/ineffective)
Description of symptom improvement
Presence or absence of adverse reactions
Changes in laboratory indicators

Tumor Treatment Extraction

Radiotherapy Information

Radiation site (chest, head and neck, pelvis, etc.)
Total dose and dose per fraction
Number of radiotherapy sessions
Radiotherapy technique (IMRT, VMAT, etc.)
Purpose of radiotherapy (radical/adjuvant/palliative)
Radiotherapy reactions

Chemotherapy Information

Chemotherapy regimen name (TP, AC-T, CHOP, etc.)
Number of cycles (which cycle/total cycles)
Chemotherapy drugs and doses
Adverse reactions and toxicity grading
Planned time for the next cycle

Targeted Therapy

Drug name and target
Dose and usage
Adverse reactions

Immunotherapy

Drug name and type (PD-1/PD-L1, etc.)
Dosage and administration
Immune-related adverse reactions

For more examples, see examples.md。