# clinical_documents

document_id: TEST_LLM_001_DOC001
document_type: cr_operatoire
creation_date: 2026-02-11 23:56:11.438858
author: Import automatique
created_at: 2026-02-11 22:56:11.439368
content:
  COMPTE-RENDU OPÉRATOIRE

  Service : Chirurgie digestive
  Date : 15 janvier 2024
  Chirurgien : Dr. Martin
  Anesthésiste : Dr. Dubois

  PATIENT
  Âge : 45 ans
  Sexe : Masculin

  DIAGNOSTIC PRÉOPÉRATOIRE
  Appendicite aiguë

  INTERVENTION RÉALISÉE
  Appendicectomie par laparoscopie

  DESCRIPTION DE L'INTERVENTION

  Patient admis aux urgences pour douleurs abdominales aiguës de la fosse iliaque droite évoluant depuis 24 heures.

  Examen clinique : défense abdominale localisée, signe de Blumberg positif.
  Biologie : hyperleucocytose à 15000/mm3, CRP élevée à 120 mg/L.
  Scanner abdominal : appendice inflammatoire de 12mm de diamètre avec infiltration de la graisse péri-appendiculaire.

  Diagnostic retenu : Appendicite aiguë avec signes de péritonite localisée.

  TECHNIQUE OPÉRATOIRE

  Installation du patient en décubitus dorsal sous anesthésie générale.
  Abord par laparoscopie avec 3 trocarts (ombilical 10mm, fosse iliaque gauche 5mm, hypogastre 5mm).

  Exploration de la cavité abdominale :
  - Appendice inflammatoire, œdématié, recouvert de fausses membranes
  - Présence de liquide purulent péri-appendiculaire (environ 50ml)
  - Pas de perforation appendiculaire
  - Reste de la cavité abdominale sans particularité

  Dissection de l'appendice et section de son méso.
  Ligature de la base appendiculaire par endoloop.
  Section de l'appendice et extraction dans un sac.
  Lavage abdominal au sérum physiologique.
  Vérification de l'hémostase.
  Fermeture des orifices de trocarts.

  SUITES OPÉRATOIRES IMMÉDIATES

  Intervention réalisée sans complication.
  Durée opératoire : 45 minutes.
  Pertes sanguines minimes.

  PRESCRIPTIONS POST-OPÉRATOIRES

  - Antalgiques : Paracétamol 1g x 4/jour
  - Antibiothérapie : Amoxicilline-acide clavulanique 1g x 3/jour pendant 5 jours
  - Reprise alimentaire progressive dès J1
  - Lever autorisé dès J0
  - Ablation des agrafes à J7

  CONCLUSION

  Appendicectomie par laparoscopie pour appendicite aiguë avec péritonite localisée.
  Suites opératoires simples attendues.
  Sortie prévue à J2 post-opératoire.

  Dr. Martin
  Chirurgien


# codes

code: F05.0
label: Délirium non surajouté à une démence, ainsi décrit
type: dp
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.555007
updated_at: 2026-02-12 00:47:39.555017
reasoning:
  Code proposé comme Diagnostic Principal. Basé sur le fait clinique: "pédiculite importante" (type: complication, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.02. Preuve textuelle: "    Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
  " (document: 15_23096332_DOC001). Sélectionné comme DP car il s'agit du diagnostic principal ayant motivé la prise en charge.


code: K80
label: Cholélithiase
type: dr
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.564200
updated_at: 2026-02-12 00:47:39.564225
reasoning:
  Code proposé comme Diagnostic Relié. Basé sur le fait clinique: "cholécystite" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Diagnostic : cholécystite" (document: 15_23096332_DOC001). Sélectionné comme DR car il s'agit du diagnostic initial ayant conduit au DP.


code: S00
label: Lésion traumatique superficielle de la tête
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.569906
updated_at: 2026-02-12 00:47:39.569913
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "vésicule nécrotique avec perforation cloisonnée" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "La vésicule est d’aspect nécrotique avec perforation cloisonnée." (document: 15_23096332_DOC001). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: UNKNOWN
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.572071
updated_at: 2026-02-12 00:47:39.572075
label:
  Constitution, des statistiques préparées conformément au présent Règlement et non communiquées en 
  v

reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "pédiculite" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.02. Preuve textuelle: "Pédiculite." (document: 15_23096332_DOC001). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: K73.8
label: Autres hépatites chroniques, non classées ailleurs
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.573900
updated_at: 2026-02-12 00:47:39.573905
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "foie fibreux" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Le foie est d’aspect fibreux" (document: 15_23096332_DOC001). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: Q89.3
label: Situs inversus
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.574879
updated_at: 2026-02-12 00:47:39.574885
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "canal cystique court" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Le canal cystique est court" (document: 15_23096332_DOC001). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: F22.9
label: Trouble délirant persistant, sans précision
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.575651
updated_at: 2026-02-12 00:47:39.575666
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "présence de calculs vésiculaires" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Présence de calcul" (document: 15_23096332_DOC001). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: K83.1
label: Obstruction des voies biliaires
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.576790
updated_at: 2026-02-12 00:47:39.576792
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "absence de canal biliaire aberrant" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "    Diagnostic : cholécystite 
      C" (document: 15_23096332_DOC001). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: A69.1
label: Autres infections dites de Vincent
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.577625
updated_at: 2026-02-12 00:47:39.577642
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "lit vésiculaire purulent" (type: complication, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Le lit vésiculaire est complètement purulent." (document: 15_23096332_DOC001). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: Z76.3
label: Personne en bonne santé accompagnant un sujet malade
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.578580
updated_at: 2026-02-12 00:47:39.578583
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "admission en urgence" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Mode d'entrée Autres admissions urgentes" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: W83
label: Autres dangers pour la respiration
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.579840
updated_at: 2026-02-12 00:47:39.579844
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "circuit long aux urgences" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Sous-type épisode URG - Circuit Long" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: K45.0
label: Autres hernies abdominales de siège précisé, avec occlusion sans gangrène
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.580862
updated_at: 2026-02-12 00:47:39.580869
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "Douleur abdominale" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Motif de prise en charge Douleur abdominale" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: F45.3
label: Dysfonctionnement neurovégétatif somatoforme
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.581640
updated_at: 2026-02-12 00:47:39.581647
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "Douleur hypochondre droit" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "douleur hypochondre droit depuis 5 jours" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: R65.0
label: Syndrome de réponse inflammatoire systémique d'origine infectieuse sans
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.582423
updated_at: 2026-02-12 00:47:39.582431
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "Syndrome inflammatoire biologique" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "sd inflammatoire biologique" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: Z61.6
label: Difficultés liées à de possibles sévices physiques infligés à un enfant
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.583101
updated_at: 2026-02-12 00:47:39.583103
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "Cholecystite" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "echo faite en ville ce jour Cholecystite" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: E13
label: Autres diabètes sucrés précisés
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.583855
updated_at: 2026-02-12 00:47:39.583865
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "Diabète non insulino-dépendant (DNID)" (type: diagnostic, certitude: affirmé, temporalité: antecedent). Score de similarité RAG: 0.03. Preuve textuelle: "ATCD DNID" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: D38.6
label: Appareil respiratoire, sans précision
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.584630
updated_at: 2026-02-12 00:47:39.584632
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "Cholécystite, sans précision" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Principal actif K81.9 Cholécystite, sans précision [CMA2] 17/05/2023 14:54" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: E66.2
label: Obésité (extrême) avec hypoventilation alvéolaire
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.585491
updated_at: 2026-02-12 00:47:39.585493
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "obésité" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Poids: 90 kg - IMC: 30.071" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: Z98.0
label: Dérivation et anastomose intestinales
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.586357
updated_at: 2026-02-12 00:47:39.586359
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "pedicultite" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.02. Preuve textuelle: "pedicultite" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: Z59.12
label: Logement inadéquat du fait de l’état de santé de la personne
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.587186
updated_at: 2026-02-12 00:47:39.587189
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "absence de transit (gaz et selles)" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Antécédents habitus (texte libre)
  Type " (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: C00.1
label: Lèvre inférieure, bord libre
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.588014
updated_at: 2026-02-12 00:47:39.588035
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "de la" (type: diagnostic, certitude: affirmé, temporalité: antecedent). Score de similarité RAG: 0.02. Preuve textuelle: "de la" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: T81.3
label: Désunion d'une plaie opératoire, non classée ailleurs
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.588807
updated_at: 2026-02-12 00:47:39.588809
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "Douleur post-opératoire" (type: complication, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Douleur: EVS 2/4 à 23h30 -> ATG1 + ATS -> soulagé" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: Y76
label: Appareils utilisés en obstétrique et en gynécologie, associés à des accidents
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.589511
updated_at: 2026-02-12 00:47:39.589514
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "Subfébrile" (type: complication, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.02. Preuve textuelle: "Risque infectieux: subfébrile à 37.9°" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: O11
label: Prééclampsie surajoutée à une hypertension chronique
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.590114
updated_at: 2026-02-12 00:47:39.590116
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "Hypertension artérielle" (type: diagnostic, certitude: affirmé, temporalité: chronique). Score de similarité RAG: 0.03. Preuve textuelle: "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (1" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: D89.3
label: Syndrome de restauration immunitaire
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.591005
updated_at: 2026-02-12 00:47:39.591007
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "Insuffisance rénale (estimation du DFG)" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.02. Preuve textuelle: "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) S" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: F50.2
label: Boulimie [bulimia nervosa]
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.591712
updated_at: 2026-02-12 00:47:39.591722
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "Hyperglycémie" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Glucose 6,7 mmol/l 10,9 mmol/l" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: J06.0
label: Laryngopharyngite aigüe
type: das
referentiel_version: 2026
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.592469
updated_at: 2026-02-12 00:47:39.592472
reasoning:
  Code proposé comme Diagnostic Associé Significatif. Basé sur le fait clinique: "Inflammation ou infection (CRP élevée)" (type: diagnostic, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "CRP 257 mg/l 313 mg/l" (document: 15_23096332_DOC004). Sélectionné comme DAS car il a eu un impact significatif sur la prise en charge.


code: HMCC003
label: Cholécystogastrostomie ou cholécystoduodénostomie, par cœlioscopie
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.593417
updated_at: 2026-02-12 00:47:39.593419
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "cholécystectomie par laparoscopie" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "CHOLECYSTECTOMIE PAR LAPAROSCOPIE" (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: HNEA740
label: Transplantation d’îlots pancréatiques par dispositif implanté, par laparotomie
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.594174
updated_at: 2026-02-12 00:47:39.594176
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "création d’un pneumopéritoine par open laparoscopie péri-ombilicale" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "    Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/" (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: GLLD013
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.594851
updated_at: 2026-02-12 00:47:39.594854
label:
  Ventilation spontanée sur trachéotomie au cours du sevrage d'une ventilation mécanique, par 24 heures

reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "introduction d’un trocart de 10 mm pour insufflation du pneumopéritoine jusqu’à 12 mm de Hg" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "    Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docte" (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: YYYY325
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.595515
updated_at: 2026-02-12 00:47:39.595517
label:
  Irradiation de 300 cm² et plus en champs fixes par accélérateur par fraction de 25 Grays pour les faisceaux de 0,5 à 4,9 MeV, incluant 3 volumes

reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "introduction de trois trocarts de 5 mm" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "    Diagnostic : cholécystite 
      Compte rendu opératoire du " (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: BGFA011
label: Vitrectomie par sclérotomie postérieure, avec extraction du cristallin
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.596120
updated_at: 2026-02-12 00:47:39.596123
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "abord et dissection du triangle de Callot et de l’infundibulum vésiculaire" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "    Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 :" (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: JKDA001
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.596692
updated_at: 2026-02-12 00:47:39.596694
label:
  Hystéropexie postérieure [Promontofixation] avec cervicocystopexie directe au ligament pectinéal [de Cooper], par laparotomie

reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "individualisation du canal cystique et de l’artère cystique" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "    Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Doct" (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: AFFA002
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.597267
updated_at: 2026-02-12 00:47:39.597268
label:
  Exérèse de tumeur en sablier extracanalaire et intracanalaire vertébrale avec reconstruction vertébrale, par abord postérieur ou postérolatéral

reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "section du canal cystique après contrôle par deux clips (HEMOLOCK 5)" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "    Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Doct" (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: HMFA006
label: Cholécystectomie par cœlioscopie, avec cholédochoduodénostomie par laparotomie
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.597954
updated_at: 2026-02-12 00:47:39.597956
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "cholécystectomie rétrograde" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "    Diagnostic : cholécystit" (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: GELE008
label: Pose d'une endoprothèse trachéobronchique, par endoscopie
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.598457
updated_at: 2026-02-12 00:47:39.598459
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "extériorisation de la vésicule dans un endosac" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.02. Preuve textuelle: "    Diagnostic : cholécystite 
      Compte rendu opératoire du 18" (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: HESE002
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.599163
updated_at: 2026-02-12 00:47:39.599165
label:
  Hémostase de lésion de l'œsophage, de l'estomac et/ou du duodénum sans laser, par œso-gastro-duodénoscopie

reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "vérification du lit vésiculaire et hémostase complémentaire ponctuelle" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "    Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opéra" (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: DEQP003
label: Électrocardiographie sur au moins 12 dérivations
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.599856
updated_at: 2026-02-12 00:47:39.599859
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "mise en place d’un drain Jackson-Pratt au niveau du lit vésiculaire" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "    Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateu" (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: NZHH004
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.600302
updated_at: 2026-02-12 00:47:39.600304
label:
  Ponction ou cytoponction d'une articulation du membre inférieur, par voie transcutanée avec guidage radiologique

reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "vérification de l’artère et du canal cystique clippés" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "    Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docteur R. DIDAILLER 
     " (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: BGNP006
label: Destruction de lésion choriorétinienne par photocoagulation transsclérale
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.600707
updated_at: 2026-02-12 00:47:39.600709
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "ablation des trocarts sous contrôle de la vue" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Ablation de tous les trocarts sous contrôle la vue" (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: LJMA005
label: Plastie de malformation sternocostale, sans ostéosynthèse
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.601089
updated_at: 2026-02-12 00:47:39.601090
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "exsufflation du pneumopéritoine" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.02. Preuve textuelle: "Exsufflation de l'ensemble du pneumopéritoine." (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: DBBF198
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.601465
updated_at: 2026-02-12 00:47:39.601466
label:
  Rétrécissement de l’orifice atrioventriculaire  gauche par dispositif par voie veineuse  transcutanée et voie transseptale  avec guidage par échographie-doppler par voie transœsophagienne

reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "fermeture aponévrotique des orifices trocart de 10 mm par un point en X de Vicryl 0" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Fermeture aponévrotique des orifices trocart de 10 mm par un point en X de Vicryl 0." (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: HJJA001
label: Drainage d'une fistule rectovaginale acquise
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.601835
updated_at: 2026-02-12 00:47:39.601836
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "fermeture cutanée par fils résorbables" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.02. Preuve textuelle: "Fermeture cutanée par fils résorbables" (document: 15_23096332_DOC001). Acte médical réalisé pendant le séjour.


code: DHNF005
label: Fibrinolyse in situ de la veine cave supérieure, par voie veineuse transcutanée
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.602198
updated_at: 2026-02-12 00:47:39.602199
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "extériorisation de la vésicule dans un endosac via trocart de 10 mm" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "    Diagnostic : cholécystite 
      Compte rendu opératoire du 18" (document: 15_23096332_DOC002). Acte médical réalisé pendant le séjour.


code: DGLF002
label: Pose d'endoprothèse couverte aorto-uniiliaque, par voie artérielle transcutanée
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.602558
updated_at: 2026-02-12 00:47:39.602560
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "passage aux urgences" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "N° Finess CENTRE HOSPITALIER COTE BASQUE
  *6400" (document: 15_23096332_DOC004). Acte médical réalisé pendant le séjour.


code: DGFA001
label: Thromboendartériectomie du tronc de l'aorte abdominale, par laparotomie
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.603008
updated_at: 2026-02-12 00:47:39.603009
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "Échographie abdominale" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "echo faite en ville ce jour" (document: 15_23096332_DOC004). Acte médical réalisé pendant le séjour.


code: YYYY108
label: Surveillance post opératoire d'un patient de chirurgie cardiaque avec CEC, niveau 1
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.603418
updated_at: 2026-02-12 00:47:39.603420
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "Hospitalisation en Médecine Chirurgie Obstétrique (MCO)" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Décision médicale Hospitalisation MCO" (document: 15_23096332_DOC004). Acte médical réalisé pendant le séjour.


code: PAMH001
label: Cimentoplastie intraosseuse extrarachidienne, par voie transcutanée avec guidage radiologique
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.603822
updated_at: 2026-02-12 00:47:39.603824
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "Retour de bloc" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "retour de bloc à 15h" (document: 15_23096332_DOC004). Acte médical réalisé pendant le séjour.


code: LBLD001
label: Pose d'un châssis métallique support de prothèse maxillofaciale [prothèse obturatrice]
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.604211
updated_at: 2026-02-12 00:47:39.604212
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "Préparation du patient pour le bloc" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Bloc: ce jour préparation patient ok" (document: 15_23096332_DOC004). Acte médical réalisé pendant le séjour.


code: AGQP006
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.604598
updated_at: 2026-02-12 00:47:39.604600
label:
  Surveillance peropératoire des potentiels évoqués moteurs, sensoriels ou somesthésiques, pendant moins de 2 heures

reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "DESINFECTION ENVIRONNEMENT PATIENT - Matin midi goûter soir - pendant 20 Jour(s)" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAXIME PAN 1 G PDR INJ -
  1000MG poudre (1 mL) - Dose 1 G - sur 20 min
  - INTRAVEINEUSE Discontinu" (document: 15_23096332_DOC004). Acte médical réalisé pendant le séjour.


code: AHQP016
label: Mesure des réflexes H et/ou T
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.604986
updated_at: 2026-02-12 00:47:39.604987
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "LEVER : AUTORISE - 2X /jour (8h 16h) - pendant 20 Jour(s)" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAXIME PAN 1 G PDR INJ -
  1000MG poudre (1 mL) - Dose 1 G - sur 20 min
  - I" (document: 15_23096332_DOC004). Acte médical réalisé pendant le séjour.


code: AHNB002
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.605416
updated_at: 2026-02-12 00:47:39.605417
label:
  Destruction sélective unilatérale ou bilatérale du nerf grand occipital [grand nerf occipital d'Arnold], par voie transcutanée

reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "DESINFECTION ENVIRONNEMENT PATIENT - Matin midi goûter soir" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAXIME PAN 1 G PDR INJ -
  1000MG pou" (document: 15_23096332_DOC004). Acte médical réalisé pendant le séjour.


code: DEFA002
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.605794
updated_at: 2026-02-12 00:47:39.605795
label:
  Exérèse ou destruction de foyer arythmogène ou de faisceau cardionecteur pour tachycardie supraventriculaire, par thoracotomie avec CEC

reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "LEVER : AUTORISE - 2X /jour (8h 16h)" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAXIME PAN 1" (document: 15_23096332_DOC004). Acte médical réalisé pendant le séjour.


code: AHQB015
label: Électromyographie de fibre unique, par électrode aiguille
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.606164
updated_at: 2026-02-12 00:47:39.606166
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "LIT : REFECTION COMPLETE - à 08h" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAXIME P" (document: 15_23096332_DOC004). Acte médical réalisé pendant le séjour.


code: JQJB001
label: Évacuation de collection d'un organe fœtal
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.606529
updated_at: 2026-02-12 00:47:39.606530
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "REPAS : INSTALLATION - Matin midi goûter soir" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.02. Preuve textuelle: "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAXIME PAN 1 G PDR IN" (document: 15_23096332_DOC004). Acte médical réalisé pendant le séjour.


code: AJNH005
label: Destruction chimique du ganglion ptérygopalatin, par voie transcutanée avec guidage radiologique
type: ccam
referentiel_version: 2025
status: proposed
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur-1.0.0
created_at: 2026-02-12 00:47:39.606885
updated_at: 2026-02-12 00:47:39.606886
reasoning:
  Code proposé comme Acte médical. Basé sur le fait clinique: "TOILETTE : AUTONOME - à 08h" (type: acte, certitude: affirmé, temporalité: actuel). Score de similarité RAG: 0.03. Preuve textuelle: "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAX" (document: 15_23096332_DOC004). Acte médical réalisé pendant le séjour.


# audit_records

record_id: audit_66e3292fe407dc4c
timestamp: 2026-02-11 22:11:25.054659
event_type: import
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
rules_version: 1.0.0
rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 22:11:25.055933
data:
  {"document_count": 2, "documents": [{"document_id": "TEST_PDF_003_DOC001", "document_type": "autre", "creation_date": "2026-02-11T23:11:25.024822", "author": "Import automatique", "priority": 1, "content_length": 81089}, {"document_id": "TEST_PDF_003_DOC002", "document_type": "cr_operatoire", "creation_date": "2026-02-11T23:11:25.042352", "author": "Import automatique", "priority": 2, "content_length": 3132}]}


record_id: audit_aab50fdbfa88d558
timestamp: 2026-02-11 22:11:25.082710
event_type: import
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
rules_version: 1.0.0
rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 22:11:25.083340
data:
  {"fact_count": 14, "facts_by_type": {"diagnostic": 5, "traitement": 8, "examen": 1}, "facts_by_certainty": {"affirm\u00e9": 14}, "facts": [{"fact_id": "9421e978-ad9b-4aca-80ec-c2e60e5912a0", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "TEST_PDF_003_DOC002"}, {"fact_id": "78c895e6-8976-4767-9424-882a68bf8eb3", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "antecedent", "confidence": 0.9, "evidence_document_id": "TEST_PDF_003_DOC001"}, {"fact_id": "4933f80a-9826-474f-b99f-a6ff80ca8426", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "antecedent", "confidence": 0.9, "evidence_document_id": "TEST_PDF_003_DOC001"}, {"fact_id": "ebc50ae2-c23b-450b-adaf-05d439f4fd7f", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "TEST_PDF_003_DOC001"}, {"fact_id": "58b2452c-1f85-4c61-81b3-70960f84c367", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "TEST_PDF_003_DOC001"}, {"fact_id": "a606c554-6703-491d-93ef-88b257e07640", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "TEST_PDF_003_DOC001"}, {"fact_id": "c765b7e0-9d8f-4b4a-b805-50868c7cc82b", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "TEST_PDF_003_DOC001"}, {"fact_id": "b7801555-24cb-42ba-b6c2-f9826e7cd62b", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "TEST_PDF_003_DOC001"}, {"fact_id": "602247d1-a381-4481-9258-710dc90b7285", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "TEST_PDF_003_DOC001"}, {"fact_id": "38b4971b-3c42-4a04-b79e-b0d4f5995304", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "TEST_PDF_003_DOC001"}, {"fact_id": "b0121daf-32e4-471f-8f7b-12e24cb34632", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "TEST_PDF_003_DOC001"}, {"fact_id": "5f78bdf0-c8d5-4716-a03a-277cf025e617", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "TEST_PDF_003_DOC001"}, {"fact_id": "c5df7f9c-e5c7-430c-b7a4-7ad5129a3bb2", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "TEST_PDF_003_DOC001"}, {"fact_id": "46df5099-b200-4921-9e11-dbf46e661987", "type": "examen", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "TEST_PDF_003_DOC001"}]}


record_id: audit_db4819b3ee61f0c1
timestamp: 2026-02-11 22:11:25.086304
event_type: coding
actor: codeur
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
rules_version: 1.0.0
rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 22:11:25.086734
data:
  {"code_counts": {"dp": 0, "dr": 0, "das": 0, "ccam": 0}, "total_codes": 0, "codes": [], "global_reasoning_length": 455}


record_id: audit_50ba4753597eb075
timestamp: 2026-02-11 22:11:25.088636
event_type: verification
actor: verificateur
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
rules_version: 1.0.0
rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 22:11:25.088967
data:
  {"decision": "accept", "dim_errors_count": 0, "dim_errors": [], "contradictions_count": 0, "alternatives_count": 0, "reasoning_length": 533}


record_id: audit_539e27bf7c6c840c
timestamp: 2026-02-11 22:11:25.091860
event_type: coding
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
rules_version: 1.0.0
rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 22:11:25.092199
data:
  {"proposal": {"dp": null, "dr": null, "das": [], "ccam": [], "reasoning": "Analyse du s\u00e9jour TEST_PDF_003 (sp\u00e9cialit\u00e9: chirurgie, dur\u00e9e: 0 jours). 14 faits cliniques ont \u00e9t\u00e9 extraits et analys\u00e9s. Aucun Diagnostic Principal (DP) n'a pu \u00eatre d\u00e9termin\u00e9 avec certitude. Approche conservative appliqu\u00e9e: les diagnostics ni\u00e9s ou suspect\u00e9s sans confirmation n'ont pas \u00e9t\u00e9 cod\u00e9s comme DP. Les ant\u00e9c\u00e9dents n'ont pas \u00e9t\u00e9 propos\u00e9s comme DP. Tous les codes propos\u00e9s sont justifi\u00e9s par des preuves textuelles extraites des documents cliniques."}, "verification": {"decision": "accept", "dim_errors": [], "contradictions": [], "alternatives": [], "reasoning": "V\u00e9rification ind\u00e9pendante de la proposition pour le s\u00e9jour TEST_PDF_003. Le V\u00e9rificateur utilise un prompt diff\u00e9rent du Codeur (verificateur=verificateur-1.0.0, codeur=codeur-1.0.0) pour garantir l'ind\u00e9pendance de l'analyse. La proposition du Codeur contient 0 code(s): DP=None, DR=None, 0 DAS, 0 CCAM. Aucune erreur sensible DIM d\u00e9tect\u00e9e. Aucune contradiction d\u00e9tect\u00e9e. D\u00e9cision du V\u00e9rificateur: ACCEPT\u00c9E - La proposition est valid\u00e9e sans r\u00e9serve. La proposition du Codeur est conforme aux exigences de qualit\u00e9 et peut \u00eatre valid\u00e9e."}}


record_id: audit_53498cd0a70c70b1
timestamp: 2026-02-11 22:11:59.708213
event_type: import
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
rules_version: 1.0.0
rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 22:11:59.709242
data:
  {"document_count": 4, "documents": [{"document_id": "21_23111304_DOC001", "document_type": "cr_operatoire", "creation_date": "2026-02-11T23:11:58.015735", "author": "Import automatique", "priority": 1, "content_length": 2905}, {"document_id": "21_23111304_DOC002", "document_type": "autre", "creation_date": "2026-02-11T23:11:58.233297", "author": "Import automatique", "priority": 2, "content_length": 15219}, {"document_id": "21_23111304_DOC003", "document_type": "autre", "creation_date": "2026-02-11T23:11:58.245947", "author": "Import automatique", "priority": 3, "content_length": 2703}, {"document_id": "21_23111304_DOC004", "document_type": "autre", "creation_date": "2026-02-11T23:11:59.696577", "author": "Import automatique", "priority": 4, "content_length": 56152}]}


record_id: audit_d818ef1f0fd4a0c3
timestamp: 2026-02-11 22:11:59.734496
event_type: import
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
rules_version: 1.0.0
rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 22:11:59.735098
data:
  {"fact_count": 27, "facts_by_type": {"diagnostic": 8, "examen": 11, "traitement": 8}, "facts_by_certainty": {"affirm\u00e9": 25, "ni\u00e9": 2}, "facts": [{"fact_id": "096dbdf7-6a11-4575-a3f9-64a6c2c7d8cd", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC001"}, {"fact_id": "3242bc17-7cdc-4d0b-a17f-2985a775063f", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "antecedent", "confidence": 0.9, "evidence_document_id": "21_23111304_DOC002"}, {"fact_id": "90b1f753-788e-4861-87b7-fbc9c4e2f8dc", "type": "examen", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC002"}, {"fact_id": "7dd6ff54-a22f-4a0d-99ab-302ce6cc3bc8", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "antecedent", "confidence": 0.9, "evidence_document_id": "21_23111304_DOC002"}, {"fact_id": "c34d3021-f7f2-47d0-9e03-14171c66b49a", "type": "examen", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC002"}, {"fact_id": "a74cf378-6749-40b5-a7e3-5855cc847b17", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "antecedent", "confidence": 0.9, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "ee242bb4-eded-451b-a4e9-db92d0eacafb", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "antecedent", "confidence": 0.9, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "c9029b07-8f72-45cc-a83f-f67aca1b6027", "type": "examen", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "e9a2b5f4-f704-4b07-9c62-1dd8a415e656", "type": "examen", "qualifier_certainty": "ni\u00e9", "temporality": "actuel", "confidence": 0.3, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "332dd6ba-3304-49a4-89c5-fa0ab8dcc039", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "antecedent", "confidence": 0.9, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "d3f37538-9a10-4730-94af-4491fc83d814", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "757fceef-f772-4464-b8fb-ff04ff8a3851", "type": "examen", "qualifier_certainty": "ni\u00e9", "temporality": "actuel", "confidence": 0.3, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "1a1c6338-79c6-47eb-b699-043cf18591a9", "type": "examen", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "1f3e22ea-a0fe-4d6d-9ece-8ccea16799f6", "type": "examen", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "ae5c4f0f-5e4e-4ded-a33a-a4017bf15a8f", "type": "examen", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "1ed3df6c-895c-452c-9579-7c0813322736", "type": "examen", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "e0cfc3c8-4bc0-44fc-82ca-6124a2795e96", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "afd18799-7b2b-4b3a-9d6c-fbc9be7f4fd7", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "08ddcd1f-1c4e-41b8-8a50-ab6d343c89ee", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "fa17bbc6-0000-44c7-a99e-ce5d12342361", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "faad260e-4673-44a1-bfab-a222cc25f74c", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "a842de38-5e64-439a-a531-12629844511d", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "5ece0987-6e25-498e-9e19-4929d81a12c9", "type": "traitement", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "f9b7cc2b-ebe3-488f-93d0-5402bba93d4b", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "b6120240-d6cd-45eb-8db2-a311c4a81760", "type": "examen", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "1fef5388-c043-4974-b5c9-0ab9eb54d637", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}, {"fact_id": "8b43095d-98b7-4a92-bfa7-74eb2a73ff33", "type": "examen", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 1.0, "evidence_document_id": "21_23111304_DOC004"}]}


record_id: audit_152c54e8249785f0
timestamp: 2026-02-11 22:11:59.737834
event_type: coding
actor: codeur
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
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prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
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inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 22:11:59.738160
data:
  {"code_counts": {"dp": 0, "dr": 0, "das": 0, "ccam": 0}, "total_codes": 0, "codes": [], "global_reasoning_length": 454}


record_id: audit_a1010491b486c6a5
timestamp: 2026-02-11 22:11:59.739993
event_type: verification
actor: verificateur
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
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inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 22:11:59.740308
data:
  {"decision": "accept", "dim_errors_count": 0, "dim_errors": [], "contradictions_count": 0, "alternatives_count": 0, "reasoning_length": 532}


record_id: audit_342a6142651713ed
timestamp: 2026-02-11 22:11:59.742301
event_type: coding
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
rules_version: 1.0.0
rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 22:11:59.742604
data:
  {"proposal": {"dp": null, "dr": null, "das": [], "ccam": [], "reasoning": "Analyse du s\u00e9jour 21_23111304 (sp\u00e9cialit\u00e9: chirurgie, dur\u00e9e: 0 jours). 25 faits cliniques ont \u00e9t\u00e9 extraits et analys\u00e9s. Aucun Diagnostic Principal (DP) n'a pu \u00eatre d\u00e9termin\u00e9 avec certitude. Approche conservative appliqu\u00e9e: les diagnostics ni\u00e9s ou suspect\u00e9s sans confirmation n'ont pas \u00e9t\u00e9 cod\u00e9s comme DP. Les ant\u00e9c\u00e9dents n'ont pas \u00e9t\u00e9 propos\u00e9s comme DP. Tous les codes propos\u00e9s sont justifi\u00e9s par des preuves textuelles extraites des documents cliniques."}, "verification": {"decision": "accept", "dim_errors": [], "contradictions": [], "alternatives": [], "reasoning": "V\u00e9rification ind\u00e9pendante de la proposition pour le s\u00e9jour 21_23111304. Le V\u00e9rificateur utilise un prompt diff\u00e9rent du Codeur (verificateur=verificateur-1.0.0, codeur=codeur-1.0.0) pour garantir l'ind\u00e9pendance de l'analyse. La proposition du Codeur contient 0 code(s): DP=None, DR=None, 0 DAS, 0 CCAM. Aucune erreur sensible DIM d\u00e9tect\u00e9e. Aucune contradiction d\u00e9tect\u00e9e. D\u00e9cision du V\u00e9rificateur: ACCEPT\u00c9E - La proposition est valid\u00e9e sans r\u00e9serve. La proposition du Codeur est conforme aux exigences de qualit\u00e9 et peut \u00eatre valid\u00e9e."}}


record_id: audit_9940ed95c9d45ba8
timestamp: 2026-02-11 22:18:27.767777
event_type: import
actor: system
model_name: mock-llm
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created_at: 2026-02-11 22:18:27.769548
data:
  {"document_count": 3, "documents": [{"document_id": "15_23096332_DOC001", "document_type": "cr_operatoire", "creation_date": "2026-02-11T23:09:28.683018", "author": "Import automatique", "priority": 1, "content_length": 3425}, {"document_id": "15_23096332_DOC002", "document_type": "cr_operatoire", "creation_date": "2026-02-11T23:09:28.700886", "author": "Import automatique", "priority": 2, "content_length": 3425}, {"document_id": "15_23096332_DOC004", "document_type": "autre", "creation_date": "2026-02-11T23:09:30.602230", "author": "Import automatique", "priority": 4, "content_length": 64722}]}


record_id: audit_3355a47f0354ef12
timestamp: 2026-02-11 22:18:27.793031
event_type: import
actor: system
model_name: mock-llm
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created_at: 2026-02-11 22:18:27.793978
data:
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record_id: audit_f5f25b75e89e521c
timestamp: 2026-02-11 22:18:27.801275
event_type: coding
actor: system
model_name: mock-llm
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created_at: 2026-02-11 22:18:27.801578
data:
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record_id: audit_f6d1d41a4def9c69
timestamp: 2026-02-11 22:27:02.455230
event_type: import
actor: system
model_name: mock-llm
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created_at: 2026-02-11 22:27:02.457258
data:
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record_id: audit_4318763b2e97a25e
timestamp: 2026-02-11 22:28:42.632583
event_type: import
actor: system
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created_at: 2026-02-11 22:28:42.634661
data:
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record_id: audit_f960ab032b093d64
timestamp: 2026-02-11 22:28:55.279435
event_type: import
actor: system
model_name: mock-llm
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record_id: audit_a7e308180810fd23
timestamp: 2026-02-11 22:37:21.709900
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record_id: audit_79d96b74de27e1bb
timestamp: 2026-02-11 22:56:11.460513
event_type: import
actor: system
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record_id: audit_c42dd3515f6096b0
timestamp: 2026-02-11 22:57:03.419850
event_type: import
actor: system
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created_at: 2026-02-11 22:57:03.420675
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record_id: audit_046d2ce1b514a086
timestamp: 2026-02-11 22:57:03.429019
event_type: coding
actor: system
model_name: mock-llm
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created_at: 2026-02-11 22:57:03.429323
data:
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record_id: audit_da136a3d0973e0dc
timestamp: 2026-02-11 23:24:33.445904
event_type: import
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created_at: 2026-02-11 23:24:33.446916
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record_id: audit_9b3fc6c430027b72
timestamp: 2026-02-11 23:25:10.058497
event_type: coding
actor: codeur
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
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created_at: 2026-02-11 23:25:10.059462
data:
  {"code_counts": {"dp": 1, "dr": 0, "das": 1, "ccam": 1}, "total_codes": 3, "codes": [{"code": "X46", "label": "Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations", "type": "dp", "confidence": 0.9400000000000001, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "V39.6", "label": "Occupant, sans pr\u00e9cision, d'un v\u00e9hicule \u00e0 moteur \u00e0 trois roues, bless\u00e9 dans une", "type": "das", "confidence": 0.776, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "UNKNOWN", "label": "- avec chol\u00e9cystectomie (cf 07.04.10) \n- avec r\u00e9section des conduits biliaires (cf 07.04.11) \n- h\u00e9pa", "type": "ccam", "confidence": 0.9400000000000001, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}], "global_reasoning_length": 630}


record_id: audit_b97c7203740d547a
timestamp: 2026-02-11 23:25:10.062279
event_type: verification
actor: verificateur
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
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groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 23:25:10.062655
data:
  {"decision": "accept", "dim_errors_count": 0, "dim_errors": [], "contradictions_count": 0, "alternatives_count": 0, "reasoning_length": 531}


record_id: audit_39c89e005cfd8acb
timestamp: 2026-02-11 23:25:10.098596
event_type: coding
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
rules_version: 1.0.0
rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 23:25:10.099377
data:
  {"proposal": {"dp": {"code": "X46", "label": "Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations", "type": "dp", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1985, "end": 2059}, "text": "Principal actif K81.9 Chol\u00e9cystite, sans pr\u00e9cision [CMA2] 17/05/2023 14:54", "context": "Diagnostic aux urgences\nType Etat Code Date\nPrincipal actif K81.9 Chol\u00e9cystite, sans pr\u00e9cision [CMA2] 17/05/2023 14:54"}], "confidence": 0.9400000000000001, "reasoning": "Code propos\u00e9 comme Diagnostic Principal. Bas\u00e9 sur le fait clinique: \"Chol\u00e9cystite, sans pr\u00e9cision\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"Principal actif K81.9 Chol\u00e9cystite, sans pr\u00e9cision [CMA2] 17/05/2023 14:54\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DP car il s'agit du diagnostic principal ayant motiv\u00e9 la prise en charge.", "referentiel_version": "2026"}, "dr": null, "das": [{"code": "V39.6", "label": "Occupant, sans pr\u00e9cision, d'un v\u00e9hicule \u00e0 moteur \u00e0 trois roues, bless\u00e9 dans une", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 5968, "end": 5982}, "text": "de la", "context": "Histoire de la\nmaladie\nDR. Julie LARRIEU-\nNARZABAL\n17/05/2023\n12..."}], "confidence": 0.776, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"de la\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: antecedent). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"de la\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}], "ccam": [{"code": "UNKNOWN", "label": "- avec chol\u00e9cystectomie (cf 07.04.10) \n- avec r\u00e9section des conduits biliaires (cf 07.04.11) \n- h\u00e9pa", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 488, "end": 521}, "text": "CHOLECYSTECTOMIE PAR LAPAROSCOPIE", "context": "...ISTIAN BERNACHOT-FAURE \n    N\u00e9 le 22/09/1949 \n    CHOLECYSTECTOMIE PAR LAPAROSCOPIE "}], "confidence": 0.9400000000000001, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"chol\u00e9cystectomie par laparoscopie\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"CHOLECYSTECTOMIE PAR LAPAROSCOPIE\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}], "reasoning": "Analyse du s\u00e9jour 15_23096332 (sp\u00e9cialit\u00e9: chirurgie, dur\u00e9e: 0 jours). 275 faits cliniques ont \u00e9t\u00e9 extraits et analys\u00e9s. Diagnostic Principal (DP): X46 - Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations (confiance: 0.94). 1 Diagnostic(s) Associ\u00e9(s) Significatif(s) (DAS) propos\u00e9(s). 1 acte(s) CCAM propos\u00e9(s). Approche conservative appliqu\u00e9e: les diagnostics ni\u00e9s ou suspect\u00e9s sans confirmation n'ont pas \u00e9t\u00e9 cod\u00e9s comme DP. Les ant\u00e9c\u00e9dents n'ont pas \u00e9t\u00e9 propos\u00e9s comme DP. Tous les codes propos\u00e9s sont justifi\u00e9s par des preuves textuelles extraites des documents cliniques."}, "verification": {"decision": "accept", "dim_errors": [], "contradictions": [], "alternatives": [], "reasoning": "V\u00e9rification ind\u00e9pendante de la proposition pour le s\u00e9jour 15_23096332. Le V\u00e9rificateur utilise un prompt diff\u00e9rent du Codeur (verificateur=verificateur-1.0.0, codeur=codeur-1.0.0) pour garantir l'ind\u00e9pendance de l'analyse. La proposition du Codeur contient 3 code(s): DP=X46, DR=None, 1 DAS, 1 CCAM. Aucune erreur sensible DIM d\u00e9tect\u00e9e. Aucune contradiction d\u00e9tect\u00e9e. D\u00e9cision du V\u00e9rificateur: ACCEPT\u00c9E - La proposition est valid\u00e9e sans r\u00e9serve. La proposition du Codeur est conforme aux exigences de qualit\u00e9 et peut \u00eatre valid\u00e9e."}}


record_id: audit_1f595ee2893c1f6c
timestamp: 2026-02-11 23:52:08.130282
event_type: import
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
rules_version: 1.0.0
rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 23:52:08.131226
data:
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record_id: audit_be0dff7dfe536836
timestamp: 2026-02-11 23:52:44.113282
event_type: coding
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
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created_at: 2026-02-11 23:52:44.114037
data:
  {"proposal": {"dp": {"code": "X46", "label": "Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations", "type": "dp", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1985, "end": 2059}, "text": "Principal actif K81.9 Chol\u00e9cystite, sans pr\u00e9cision [CMA2] 17/05/2023 14:54", "context": "Diagnostic aux urgences\nType Etat Code Date\nPrincipal actif K81.9 Chol\u00e9cystite, sans pr\u00e9cision [CMA2] 17/05/2023 14:54"}], "confidence": 0.9400000000000001, "reasoning": "Code propos\u00e9 comme Diagnostic Principal. Bas\u00e9 sur le fait clinique: \"Chol\u00e9cystite, sans pr\u00e9cision\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"Principal actif K81.9 Chol\u00e9cystite, sans pr\u00e9cision [CMA2] 17/05/2023 14:54\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DP car il s'agit du diagnostic principal ayant motiv\u00e9 la prise en charge.", "referentiel_version": "2026"}, "dr": null, "das": [{"code": "V39.6", "label": "Occupant, sans pr\u00e9cision, d'un v\u00e9hicule \u00e0 moteur \u00e0 trois roues, bless\u00e9 dans une", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 5968, "end": 5982}, "text": "de la", "context": "Histoire de la\nmaladie\nDR. Julie LARRIEU-\nNARZABAL\n17/05/2023\n12..."}], "confidence": 0.776, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"de la\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: antecedent). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"de la\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}], "ccam": [{"code": "UNKNOWN", "label": "- avec chol\u00e9cystectomie (cf 07.04.10) \n- avec r\u00e9section des conduits biliaires (cf 07.04.11) \n- h\u00e9pa", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 488, "end": 521}, "text": "CHOLECYSTECTOMIE PAR LAPAROSCOPIE", "context": "...ISTIAN BERNACHOT-FAURE \n    N\u00e9 le 22/09/1949 \n    CHOLECYSTECTOMIE PAR LAPAROSCOPIE "}], "confidence": 0.9400000000000001, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"chol\u00e9cystectomie par laparoscopie\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"CHOLECYSTECTOMIE PAR LAPAROSCOPIE\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}], "reasoning": "Analyse du s\u00e9jour 15_23096332 (sp\u00e9cialit\u00e9: chirurgie, dur\u00e9e: 0 jours). 278 faits cliniques ont \u00e9t\u00e9 extraits et analys\u00e9s. Diagnostic Principal (DP): X46 - Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations (confiance: 0.94). 1 Diagnostic(s) Associ\u00e9(s) Significatif(s) (DAS) propos\u00e9(s). 1 acte(s) CCAM propos\u00e9(s). Approche conservative appliqu\u00e9e: les diagnostics ni\u00e9s ou suspect\u00e9s sans confirmation n'ont pas \u00e9t\u00e9 cod\u00e9s comme DP. Les ant\u00e9c\u00e9dents n'ont pas \u00e9t\u00e9 propos\u00e9s comme DP. Tous les codes propos\u00e9s sont justifi\u00e9s par des preuves textuelles extraites des documents cliniques."}, "verification": {"decision": "accept", "dim_errors": [], "contradictions": [], "alternatives": [], "reasoning": "V\u00e9rification ind\u00e9pendante de la proposition pour le s\u00e9jour 15_23096332. Le V\u00e9rificateur utilise un prompt diff\u00e9rent du Codeur (verificateur=verificateur-1.0.0, codeur=codeur-1.0.0) pour garantir l'ind\u00e9pendance de l'analyse. La proposition du Codeur contient 3 code(s): DP=X46, DR=None, 1 DAS, 1 CCAM. Aucune erreur sensible DIM d\u00e9tect\u00e9e. Aucune contradiction d\u00e9tect\u00e9e. D\u00e9cision du V\u00e9rificateur: ACCEPT\u00c9E - La proposition est valid\u00e9e sans r\u00e9serve. La proposition du Codeur est conforme aux exigences de qualit\u00e9 et peut \u00eatre valid\u00e9e."}}


record_id: audit_0dabf81eaba0c369
timestamp: 2026-02-11 23:54:45.281028
event_type: import
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
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created_at: 2026-02-11 23:54:45.282042
data:
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record_id: audit_389ff5ca82bef744
timestamp: 2026-02-11 23:55:20.391654
event_type: coding
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
rules_version: 1.0.0
rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-11 23:55:20.392435
data:
  {"proposal": {"dp": {"code": "X46", "label": "Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations", "type": "dp", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1985, "end": 2059}, "text": "Principal actif K81.9 Chol\u00e9cystite, sans pr\u00e9cision [CMA2] 17/05/2023 14:54", "context": "Diagnostic aux urgences\nType Etat Code Date\nPrincipal actif K81.9 Chol\u00e9cystite, sans pr\u00e9cision [CMA2] 17/05/2023 14:54"}], "confidence": 0.9400000000000001, "reasoning": "Code propos\u00e9 comme Diagnostic Principal. Bas\u00e9 sur le fait clinique: \"Chol\u00e9cystite, sans pr\u00e9cision\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"Principal actif K81.9 Chol\u00e9cystite, sans pr\u00e9cision [CMA2] 17/05/2023 14:54\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DP car il s'agit du diagnostic principal ayant motiv\u00e9 la prise en charge.", "referentiel_version": "2026"}, "dr": null, "das": [{"code": "V39.6", "label": "Occupant, sans pr\u00e9cision, d'un v\u00e9hicule \u00e0 moteur \u00e0 trois roues, bless\u00e9 dans une", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 5968, "end": 5982}, "text": "de la", "context": "Histoire de la\nmaladie\nDR. Julie LARRIEU-\nNARZABAL\n17/05/2023\n12..."}], "confidence": 0.776, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"de la\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: antecedent). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"de la\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}], "ccam": [{"code": "UNKNOWN", "label": "- avec chol\u00e9cystectomie (cf 07.04.10) \n- avec r\u00e9section des conduits biliaires (cf 07.04.11) \n- h\u00e9pa", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 488, "end": 521}, "text": "CHOLECYSTECTOMIE PAR LAPAROSCOPIE", "context": "...ISTIAN BERNACHOT-FAURE \n    N\u00e9 le 22/09/1949 \n    CHOLECYSTECTOMIE PAR LAPAROSCOPIE "}], "confidence": 0.9400000000000001, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"CHOLECYSTECTOMIE PAR LAPAROSCOPIE\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"CHOLECYSTECTOMIE PAR LAPAROSCOPIE\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}], "reasoning": "Analyse du s\u00e9jour 15_23096332 (sp\u00e9cialit\u00e9: chirurgie, dur\u00e9e: 0 jours). 276 faits cliniques ont \u00e9t\u00e9 extraits et analys\u00e9s. Diagnostic Principal (DP): X46 - Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations (confiance: 0.94). 1 Diagnostic(s) Associ\u00e9(s) Significatif(s) (DAS) propos\u00e9(s). 1 acte(s) CCAM propos\u00e9(s). Approche conservative appliqu\u00e9e: les diagnostics ni\u00e9s ou suspect\u00e9s sans confirmation n'ont pas \u00e9t\u00e9 cod\u00e9s comme DP. Les ant\u00e9c\u00e9dents n'ont pas \u00e9t\u00e9 propos\u00e9s comme DP. Tous les codes propos\u00e9s sont justifi\u00e9s par des preuves textuelles extraites des documents cliniques."}, "verification": {"decision": "accept", "dim_errors": [], "contradictions": [], "alternatives": [], "reasoning": "V\u00e9rification ind\u00e9pendante de la proposition pour le s\u00e9jour 15_23096332. Le V\u00e9rificateur utilise un prompt diff\u00e9rent du Codeur (verificateur=verificateur-1.0.0, codeur=codeur-1.0.0) pour garantir l'ind\u00e9pendance de l'analyse. La proposition du Codeur contient 3 code(s): DP=X46, DR=None, 1 DAS, 1 CCAM. Aucune erreur sensible DIM d\u00e9tect\u00e9e. Aucune contradiction d\u00e9tect\u00e9e. D\u00e9cision du V\u00e9rificateur: ACCEPT\u00c9E - La proposition est valid\u00e9e sans r\u00e9serve. La proposition du Codeur est conforme aux exigences de qualit\u00e9 et peut \u00eatre valid\u00e9e."}}


record_id: audit_fbedb001a944437a
timestamp: 2026-02-12 00:00:40.631219
event_type: import
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
prompt_hash: 09076c162c806591af8bb055750006c411ef7f04d69337e3713a8e17b9cd7739
rules_version: 1.0.0
rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
groupage_version: 2026
referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-12 00:00:40.632008
data:
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record_id: audit_fa9230cf5c8f3693
timestamp: 2026-02-12 00:01:12.681700
event_type: coding
actor: codeur
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
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referentiels_versions: {}
inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-12 00:01:12.682665
data:
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record_id: audit_35ea36af25d8ad90
timestamp: 2026-02-12 00:01:12.715721
event_type: coding
actor: system
model_name: mock-llm
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prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
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  {"proposal": {"dp": {"code": "X46", "label": "Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations", "type": "dp", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1985, "end": 2059}, "text": "Principal actif K81.9 Chol\u00e9cystite, sans pr\u00e9cision [CMA2] 17/05/2023 14:54", "context": "Diagnostic aux urgences\nType Etat Code Date\nPrincipal actif K81.9 Chol\u00e9cystite, sans pr\u00e9cision [CMA2] 17/05/2023 14:54"}], "confidence": 0.9400000000000001, "reasoning": "Code propos\u00e9 comme Diagnostic Principal. Bas\u00e9 sur le fait clinique: \"Chol\u00e9cystite, sans pr\u00e9cision\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"Principal actif K81.9 Chol\u00e9cystite, sans pr\u00e9cision [CMA2] 17/05/2023 14:54\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DP car il s'agit du diagnostic principal ayant motiv\u00e9 la prise en charge.", "referentiel_version": "2026"}, "dr": null, "das": [], "ccam": [{"code": "UNKNOWN", "label": "- avec chol\u00e9cystectomie (cf 07.04.10) \n- avec r\u00e9section des conduits biliaires (cf 07.04.11) \n- h\u00e9pa", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 488, "end": 521}, "text": "CHOLECYSTECTOMIE PAR LAPAROSCOPIE", "context": "...ISTIAN BERNACHOT-FAURE \n    N\u00e9 le 22/09/1949 \n    CHOLECYSTECTOMIE PAR LAPAROSCOPIE "}], "confidence": 0.9400000000000001, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"chol\u00e9cystectomie par laparoscopie\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"CHOLECYSTECTOMIE PAR LAPAROSCOPIE\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}], "reasoning": "Analyse du s\u00e9jour 15_23096332 (sp\u00e9cialit\u00e9: chirurgie, dur\u00e9e: 0 jours). 290 faits cliniques ont \u00e9t\u00e9 extraits et analys\u00e9s. Diagnostic Principal (DP): X46 - Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations (confiance: 0.94). 1 acte(s) CCAM propos\u00e9(s). Approche conservative appliqu\u00e9e: les diagnostics ni\u00e9s ou suspect\u00e9s sans confirmation n'ont pas \u00e9t\u00e9 cod\u00e9s comme DP. Les ant\u00e9c\u00e9dents n'ont pas \u00e9t\u00e9 propos\u00e9s comme DP. Tous les codes propos\u00e9s sont justifi\u00e9s par des preuves textuelles extraites des documents cliniques."}, "verification": {"decision": "accept", "dim_errors": [], "contradictions": [], "alternatives": [], "reasoning": "V\u00e9rification ind\u00e9pendante de la proposition pour le s\u00e9jour 15_23096332. Le V\u00e9rificateur utilise un prompt diff\u00e9rent du Codeur (verificateur=verificateur-1.0.0, codeur=codeur-1.0.0) pour garantir l'ind\u00e9pendance de l'analyse. La proposition du Codeur contient 2 code(s): DP=X46, DR=None, 0 DAS, 1 CCAM. Aucune erreur sensible DIM d\u00e9tect\u00e9e. Aucune contradiction d\u00e9tect\u00e9e. D\u00e9cision du V\u00e9rificateur: ACCEPT\u00c9E - La proposition est valid\u00e9e sans r\u00e9serve. La proposition du Codeur est conforme aux exigences de qualit\u00e9 et peut \u00eatre valid\u00e9e."}}


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timestamp: 2026-02-12 00:09:17.384528
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