{ "fichier": "OGC 74", "pdf_hash": "58076293464e9771", "schema_version": "2.0", "extraction": { "recueil": { "etablissement": "CLINIQUE D'ARCACHON", "finess": "330780206", "date_debut_controle": "13/02/2018", "n_ogc": "74", "n_champ": "1", "dates_sejour": "08/04/2016 au 13/04/2016", "sejour_etab": { "age": "52", "sexe": "1", "duree_sejour": "5", "mode_entree": "1", "provenance": "8", "mode_sortie": "1", "destination": "8" }, "sejour_reco": { "age": "52", "sexe": "1", "duree_sejour": "5", "mode_entree": "1", "provenance": "8", "mode_sortie": "1", "destination": "8" }, "rum_etab": { "um": "40 C", "igs": "II", "duree": "5", "dates": "du 08/04/2016 au 13/04/2016" }, "codage_etab": { "dp": "A099", "dp_libelle": "GASTROENTERITE COLITE ORIGINE SAI", "dr": "C795 * 2", "das": [] }, "codage_reco": { "dp": "A099", "dr": "C795 * 2", "das": [] }, "actes_etab": [], "actes_reco": [], "ghm_etab": "06M032", "ghs_etab": "2130", "ghm_reco": "18M041", "ghs_reco": "6772", "recodage_impactant": "1", "ghs_injustifie": "0", "accord_desaccord": "désaccord", "praticien_conseil": "DR JP VIGNAU", "_validation": { "summary": { "valid": 8, "invalid": 0, "empty": 0, "total_codes": 8, "ghm_ghs_incoherents": 0 }, "codage_etab": { "dp": { "valid": true, "libelle_ref": "Gastroentérite et colite d’origine non précisée" }, "dr": { "valid": true, "libelle_ref": "Tumeur maligne secondaire des os et de la moelle osseuse" }, "das": [] }, "codage_reco": { "dp": { "valid": true, "libelle_ref": "Gastroentérite et colite d’origine non précisée" }, "dr": { "valid": true, "libelle_ref": "Tumeur maligne secondaire des os et de la moelle osseuse" }, "das": [] }, "ghm_etab": { "valid": true }, "ghs_etab": { "valid": true }, "ghm_reco": { "valid": true }, "ghs_reco": { "valid": true }, "cross_checks": { "etab_ghm_ghs_coherent": true, "reco_ghm_ghs_coherent": true } } }, "concertation_2": { "ghs_initial": "", "ghs_avant_concertation": "", "ghs_final": "", "decision": "", "date_concertation": "2-3", "praticien_controleur": "", "medecin_dim": "", "_validation": { "ghs_initial": { "code": "", "valid": null }, "ghs_avant_concertation": { "code": "", "valid": null }, "ghs_final": { "code": "", "valid": null } } }, "concertation_1": { "date_concertation": "2.3.18", "argumentaire": "Atteste avoir pris connaissance des éléments du dossier y compris ceux couverts par le secret médical et des arguments soutenus par les médecins contrôleurs et avoir eu l'opportunité d'en débattre contradictoirement" }, "preuves": { "date": "2023/01/18", "praticien_controleur": [ "Dr RADZIKOWSKI", "Dr DELAYE-PHULPIN", "Dr TURBAN", "Dr DUVAL", "Dr VIGNAU", "Dr PROMAX" ], "medecin_dim": "Dr ETTORCHI-TARDY", "pieces": [ { "intitule": "Compte-rendu d'acte : TDP TAP TRN", "present": true, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Compte-rendu opératoire", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Compte-rendu d'accouchement", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Compte-rendu d'examen complémentaire :", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Compte-rendu d'imagerie :", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Compte-rendu d'anatomopathologie", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Observations médicales", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Dossier de transfusion", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Dossier d'anesthésie", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Administration thérapeutique", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Compte-rendu d'hospitalisation", "present": true, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Lettre de sortie", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Eléments de surveillance du dossier infirmier", "present": true, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Prise en charge psychologique", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Prise en charge kinésithérapeute", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Prise en charge diététique", "present": false, "photocopie": false, "absent_date": "", "date_obtention": "" }, { "intitule": "Autre : b-c", "present": true, "photocopie": false, "absent_date": "", "date_obtention": "" } ] } }, "_meta": { "pipeline_version": "v1", "ocr_model": "zai-org/GLM-OCR", "generated_at": "2026-04-24T12:16:17+00:00" } }