# audit_records

record_id: audit_c071a22b1c8bbc31
timestamp: 2026-02-12 00:47:37.220059
event_type: coding
actor: codeur
model_name: mock-llm
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data:
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en bonne sant\u00e9 accompagnant un sujet malade", "type": "das", "confidence": 0.5519509476031216, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "W83", "label": "Autres dangers pour la respiration", "type": "das", "confidence": 0.550945644080417, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "K45.0", "label": "Autres hernies abdominales de si\u00e8ge pr\u00e9cis\u00e9, avec occlusion sans gangr\u00e8ne", "type": "das", "confidence": 0.5523544784984558, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "F45.3", "label": "Dysfonctionnement neurov\u00e9g\u00e9tatif somatoforme", "type": "das", "confidence": 0.5523193556029378, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "R65.0", "label": "Syndrome de r\u00e9ponse inflammatoire syst\u00e9mique d'origine infectieuse sans", "type": "das", "confidence": 0.5528008192524322, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "Z61.6", "label": "Difficult\u00e9s li\u00e9es \u00e0 de possibles s\u00e9vices physiques inflig\u00e9s \u00e0 un enfant", "type": "das", "confidence": 0.5506502816180237, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "E13", "label": "Autres diab\u00e8tes sucr\u00e9s pr\u00e9cis\u00e9s", "type": "das", "confidence": 0.4208071919619249, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "D38.6", "label": "Appareil respiratoire, sans pr\u00e9cision", "type": "das", "confidence": 0.5513480885311872, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "E66.2", "label": "Ob\u00e9sit\u00e9 (extr\u00eame) avec hypoventilation alv\u00e9olaire", "type": "das", "confidence": 0.5530089899524062, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "Z98.0", "label": "D\u00e9rivation et anastomose intestinales", "type": "das", "confidence": 0.5487796731480377, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "Z59.12", "label": "Logement inad\u00e9quat du fait de l\u2019\u00e9tat de sant\u00e9 de la personne", "type": "das", "confidence": 0.5504800540906019, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "C00.1", "label": "L\u00e8vre inf\u00e9rieure, bord libre", "type": "das", "confidence": 0.4637842646649986, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "T81.3", "label": "D\u00e9sunion d'une plaie op\u00e9ratoire, non class\u00e9e ailleurs", "type": "das", "confidence": 0.5515573770491804, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "Y76", "label": "Appareils utilis\u00e9s en obst\u00e9trique et en gyn\u00e9cologie, associ\u00e9s \u00e0 des accidents", "type": "das", "confidence": 0.5482326997794813, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "O11", "label": "Pr\u00e9\u00e9clampsie surajout\u00e9e \u00e0 une hypertension chronique", "type": "das", "confidence": 0.5393008192524322, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "D89.3", "label": "Syndrome de restauration immunitaire", "type": "das", "confidence": 0.54995115995116, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "F50.2", "label": "Boulimie [bulimia nervosa]", "type": "das", "confidence": 0.5512877583465818, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "J06.0", "label": "Laryngopharyngite aig\u00fce", "type": "das", "confidence": 0.5517672507030067, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "HMCC003", "label": "Chol\u00e9cystogastrostomie ou chol\u00e9cystoduod\u00e9nostomie, par c\u0153lioscopie", "type": "ccam", "confidence": 0.5529065833983867, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "HNEA740", "label": "Transplantation d\u2019\u00eelots pancr\u00e9atiques par dispositif implant\u00e9, par laparotomie", "type": "ccam", "confidence": 0.5509052031361369, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "GLLD013", "label": "Ventilation spontan\u00e9e sur trach\u00e9otomie au cours du sevrage d'une ventilation m\u00e9canique, par 24 heures", "type": "ccam", "confidence": 0.5518570183086313, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "YYYY325", "label": "Irradiation de 300 cm\u00b2 et plus en champs fixes par acc\u00e9l\u00e9rateur par fraction de 25 Grays pour les faisceaux de 0,5 \u00e0 4,9 MeV, incluant 3 volumes", "type": "ccam", "confidence": 0.5524217621569572, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "BGFA011", "label": "Vitrectomie par scl\u00e9rotomie post\u00e9rieure, avec extraction du cristallin", "type": "ccam", "confidence": 0.5510334403929719, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "JKDA001", "label": "Hyst\u00e9ropexie post\u00e9rieure [Promontofixation] avec cervicocystopexie directe au ligament pectin\u00e9al [de Cooper], par laparotomie", "type": "ccam", "confidence": 0.5502271018198226, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "AFFA002", "label": "Ex\u00e9r\u00e8se de tumeur en sablier extracanalaire et intracanalaire vert\u00e9brale avec reconstruction vert\u00e9brale, par abord post\u00e9rieur ou post\u00e9rolat\u00e9ral", "type": "ccam", "confidence": 0.5503396851698426, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "HMFA006", "label": "Chol\u00e9cystectomie par c\u0153lioscopie, avec chol\u00e9dochoduod\u00e9nostomie par laparotomie", "type": "ccam", "confidence": 0.5529032258064517, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "GELE008", "label": "Pose d'une endoproth\u00e8se trach\u00e9obronchique, par endoscopie", "type": "ccam", "confidence": 0.5499821746880571, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "HESE002", "label": "H\u00e9mostase de l\u00e9sion de l'\u0153sophage, de l'estomac et/ou du duod\u00e9num sans laser, par \u0153so-gastro-duod\u00e9noscopie", "type": "ccam", "confidence": 0.5515149040424663, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "DEQP003", "label": "\u00c9lectrocardiographie sur au moins 12 d\u00e9rivations", "type": "ccam", "confidence": 0.5520307553143374, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "NZHH004", "label": "Ponction ou cytoponction d'une articulation du membre inf\u00e9rieur, par voie transcutan\u00e9e avec guidage radiologique", "type": 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true}, {"code": "JQJB001", "label": "\u00c9vacuation de collection d'un organe f\u0153tal", "type": "ccam", "confidence": 0.5465573770491803, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "AJNH005", "label": "Destruction chimique du ganglion pt\u00e9rygopalatin, par voie transcutan\u00e9e avec guidage radiologique", "type": "ccam", "confidence": 0.5504120089428298, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}], "global_reasoning_length": 642}


record_id: audit_0c12408712fdefe0
timestamp: 2026-02-12 00:47:37.231318
event_type: verification
actor: verificateur
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created_at: 2026-02-12 00:47:37.233121
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record_id: audit_e31d5fe00c3aa3ce
timestamp: 2026-02-12 00:47:39.540729
event_type: coding
actor: system
model_name: mock-llm
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created_at: 2026-02-12 00:47:39.542761
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  {"proposal": {"dp": {"code": "F05.0", "label": "D\u00e9lirium non surajout\u00e9 \u00e0 une d\u00e9mence, ainsi d\u00e9crit", "type": "dp", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 599}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n    Anesth\u00e9s..."}], "confidence": 0.548389480547707, "reasoning": "Code propos\u00e9 comme Diagnostic Principal. Bas\u00e9 sur le fait clinique: \"p\u00e9diculite importante\" (type: complication, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.02. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n\" (document: 15_23096332_DOC001). S\u00e9lectionn\u00e9 comme DP car il s'agit du diagnostic principal ayant motiv\u00e9 la prise en charge.", "referentiel_version": "2026"}, "dr": {"code": "K80", "label": "Chol\u00e9lithiase", "type": "dr", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 527, "end": 552}, "text": "Diagnostic : chol\u00e9cystite", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n   ..."}], "confidence": 0.550261080752884, "reasoning": "Code propos\u00e9 comme Diagnostic Reli\u00e9. Bas\u00e9 sur le fait clinique: \"chol\u00e9cystite\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Diagnostic : chol\u00e9cystite\" (document: 15_23096332_DOC001). S\u00e9lectionn\u00e9 comme DR car il s'agit du diagnostic initial ayant conduit au DP.", "referentiel_version": "2026"}, "das": [{"code": "S00", "label": "L\u00e9sion traumatique superficielle de la t\u00eate", "type": "das", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 770, "end": 834}, "text": "La v\u00e9sicule est d\u2019aspect n\u00e9crotique avec perforation cloisonn\u00e9e.", "context": "...aparoscopie \n    Constatations op\u00e9ratoires : \n    La v\u00e9sicule est d\u2019aspect n\u00e9crotique avec perforation cloisonn\u00e9e. P\u00e9diculite. \n    Le foie est d\u2019aspect fibreux \n  ..."}], "confidence": 0.5523544784984558, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"v\u00e9sicule n\u00e9crotique avec perforation cloisonn\u00e9e\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"La v\u00e9sicule est d\u2019aspect n\u00e9crotique avec perforation cloisonn\u00e9e.\" (document: 15_23096332_DOC001). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "UNKNOWN", "label": "Constitution, des statistiques pr\u00e9par\u00e9es conform\u00e9ment au pr\u00e9sent R\u00e8glement et non communiqu\u00e9es en \nv", "type": "das", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 835, "end": 846}, "text": "P\u00e9diculite.", "context": "... d\u2019aspect n\u00e9crotique avec perforation cloisonn\u00e9e. P\u00e9diculite. \n    Le foie est d\u2019aspect fibreux \n    Le canal c..."}], "confidence": 0.5465573770491803, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"p\u00e9diculite\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.02. Preuve textuelle: \"P\u00e9diculite.\" (document: 15_23096332_DOC001). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "K73.8", "label": "Autres h\u00e9patites chroniques, non class\u00e9es ailleurs", "type": "das", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 852, "end": 880}, "text": "Le foie est d\u2019aspect fibreux", "context": "...que avec perforation cloisonn\u00e9e. P\u00e9diculite. \n    Le foie est d\u2019aspect fibreux \n    Le canal cystique est court \n    Cholangiogr..."}], "confidence": 0.5523544784984558, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"foie fibreux\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Le foie est d\u2019aspect fibreux\" (document: 15_23096332_DOC001). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "Q89.3", "label": "Situs inversus", "type": "das", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 886, "end": 913}, "text": "Le canal cystique est court", "context": "...\u00e9diculite. \n    Le foie est d\u2019aspect fibreux \n    Le canal cystique est court \n    Cholangiographie per-op\u00e9ratoire : Essai mais..."}], "confidence": 0.5522487143525012, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"canal cystique court\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Le canal cystique est court\" (document: 15_23096332_DOC001). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "F22.9", "label": "Trouble d\u00e9lirant persistant, sans pr\u00e9cision", "type": "das", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 3060, "end": 3078}, "text": "Pr\u00e9sence de calcul", "context": "...men anatomopa thologique : Aspect macroscopique : Pr\u00e9sence de calcul \n    perforation de la v\u00e9sicule, Absence d\u2019un can..."}], "confidence": 0.5504482642399731, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"pr\u00e9sence de calculs v\u00e9siculaires\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Pr\u00e9sence de calcul\" (document: 15_23096332_DOC001). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "K83.1", "label": "Obstruction des voies biliaires", "type": "das", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 559}, "text": "    Diagnostic : chol\u00e9cystite \n    C", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rat..."}], "confidence": 0.5529065833983867, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"absence de canal biliaire aberrant\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    C\" (document: 15_23096332_DOC001). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "A69.1", "label": "Autres infections dites de Vincent", "type": "das", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 1949, "end": 1994}, "text": "Le lit v\u00e9siculaire est compl\u00e8tement purulent.", "context": "...tion d'h \u00e9mostase compl\u00e9mentaire ponctuelle. \n    Le lit v\u00e9siculaire est compl\u00e8tement purulent. On me ttra donc un Jackson-Pratt au niveau du lit..."}], "confidence": 0.5516554054054055, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"lit v\u00e9siculaire purulent\" (type: complication, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Le lit v\u00e9siculaire est compl\u00e8tement purulent.\" (document: 15_23096332_DOC001). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "Z76.3", "label": "Personne en bonne sant\u00e9 accompagnant un sujet malade", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1003, "end": 1043}, "text": "Mode d'entr\u00e9e Autres admissions urgentes", "context": "...M\u00e9dicalisation du transport Aucune m\u00e9dicalisation\nMode d'entr\u00e9e Autres admissions urgentes\nDate d'orientation 17/05/2023\nHeure d'orientation..."}], "confidence": 0.5519509476031216, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"admission en urgence\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Mode d'entr\u00e9e Autres admissions urgentes\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "W83", "label": "Autres dangers pour la respiration", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1139, "end": 1175}, "text": "Sous-type \u00e9pisode URG - Circuit Long", "context": "...tion 11:44\nIAO VASSEUR Sabine\nPriorit\u00e9 Priorit\u00e9 3\nSous-type \u00e9pisode URG - Circuit Long"}], "confidence": 0.550945644080417, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"circuit long aux urgences\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Sous-type \u00e9pisode URG - Circuit Long\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "K45.0", "label": "Autres hernies abdominales de si\u00e8ge pr\u00e9cis\u00e9, avec occlusion sans gangr\u00e8ne", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1176, "end": 1219}, "text": "Motif de prise en charge Douleur abdominale", "context": "Motif de prise en charge Douleur abdominale\nObserv. IDE Urg\ndouleur hypochondre droit depuis ..."}], "confidence": 0.5523544784984558, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Douleur abdominale\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Motif de prise en charge Douleur abdominale\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "F45.3", "label": "Dysfonctionnement neurov\u00e9g\u00e9tatif somatoforme", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1236, "end": 1276}, "text": "douleur hypochondre droit depuis 5 jours", "context": "...rise en charge Douleur abdominale\nObserv. IDE Urg\ndouleur hypochondre droit depuis 5 jours, sd inflammatoire biologique, echo faite en ville..."}], "confidence": 0.5523193556029378, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Douleur hypochondre droit\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"douleur hypochondre droit depuis 5 jours\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "R65.0", "label": "Syndrome de r\u00e9ponse inflammatoire syst\u00e9mique d'origine infectieuse sans", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1278, "end": 1305}, "text": "sd inflammatoire biologique", "context": "...IDE Urg\ndouleur hypochondre droit depuis 5 jours, sd inflammatoire biologique, echo faite en ville ce jour Cholecystite\nAntalgi..."}], "confidence": 0.5528008192524322, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Syndrome inflammatoire biologique\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"sd inflammatoire biologique\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "Z61.6", "label": "Difficult\u00e9s li\u00e9es \u00e0 de possibles s\u00e9vices physiques inflig\u00e9s \u00e0 un enfant", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1307, "end": 1347}, "text": "echo faite en ville ce jour Cholecystite", "context": "...roit depuis 5 jours, sd inflammatoire biologique, echo faite en ville ce jour Cholecystite\nAntalgie par palier II et Ibuprofene\nATCD DNID\nM\u00e9..."}], "confidence": 0.5506502816180237, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Cholecystite\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"echo faite en ville ce jour Cholecystite\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "E13", "label": "Autres diab\u00e8tes sucr\u00e9s pr\u00e9cis\u00e9s", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1385, "end": 1394}, "text": "ATCD DNID", "context": "...Cholecystite\nAntalgie par palier II et Ibuprofene\nATCD DNID\nM\u00e9decin de la prise en charge m\u00e9dicale LARRIEU--N..."}], "confidence": 0.4208071919619249, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Diab\u00e8te non insulino-d\u00e9pendant (DNID)\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: antecedent). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"ATCD DNID\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "D38.6", "label": "Appareil respiratoire, sans pr\u00e9cision", "type": "das", "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": 0.5513480885311872, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Chol\u00e9cystite, sans pr\u00e9cision\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. 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 DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "E66.2", "label": "Ob\u00e9sit\u00e9 (extr\u00eame) avec hypoventilation alv\u00e9olaire", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 2325, "end": 2351}, "text": "Poids: 90 kg - IMC: 30.071", "context": "...ISCERALE - CHIRURGIE VISC.A2 ) - Taille: 173 cm - Poids: 90 kg - IMC: 30.071\nLe 20/05/2023 14:40 Page 1 de 24\n"}], "confidence": 0.5530089899524062, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"ob\u00e9sit\u00e9\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Poids: 90 kg - IMC: 30.071\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "Z98.0", "label": "D\u00e9rivation et anastomose intestinales", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 5611, "end": 5622}, "text": "pedicultite", "context": "...l\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e\npedicultite\n2hemoclock de 5 sur l'art\u00e8re hemlock de 5 sur le ..."}], "confidence": 0.5487796731480377, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"pedicultite\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.02. Preuve textuelle: \"pedicultite\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "Z59.12", "label": "Logement inad\u00e9quat du fait de l\u2019\u00e9tat de sant\u00e9 de la personne", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 2386, "end": 2425}, "text": "Ant\u00e9c\u00e9dents habitus (texte libre)\nType ", "context": "Ant\u00e9c\u00e9dents habitus (texte libre)\nType de note Nom Date Heure Note\nAucune donn\u00e9e\nrenseign..."}], "confidence": 0.5504800540906019, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"absence de transit (gaz et selles)\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Ant\u00e9c\u00e9dents habitus (texte libre)\nType \" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "C00.1", "label": "L\u00e8vre inf\u00e9rieure, bord libre", "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": 0.4637842646649986, "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: 0.02. 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"}, {"code": "T81.3", "label": "D\u00e9sunion d'une plaie op\u00e9ratoire, non class\u00e9e ailleurs", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 8786, "end": 8835}, "text": "Douleur: EVS 2/4 \u00e0 23h30 -> ATG1 + ATS -> soulag\u00e9", "context": ".../05/2023\n23:25\nJ1 Chol\u00e9cystectomie\nSurv POst Op:\n-Douleur: EVS 2/4 \u00e0 23h30 -> ATG1 + ATS -> soulag\u00e9\nConstantes stables et dans les normes\n-Risque inf..."}], "confidence": 0.5515573770491804, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Douleur post-op\u00e9ratoire\" (type: complication, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Douleur: EVS 2/4 \u00e0 23h30 -> ATG1 + ATS -> soulag\u00e9\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "Y76", "label": "Appareils utilis\u00e9s en obst\u00e9trique et en gyn\u00e9cologie, associ\u00e9s \u00e0 des accidents", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 8875, "end": 8912}, "text": "Risque infectieux: subf\u00e9brile \u00e0 37.9\u00b0", "context": "...-> soulag\u00e9\nConstantes stables et dans les normes\n-Risque infectieux: subf\u00e9brile \u00e0 37.9\u00b0 -> d\u00e9couvert recontrol\u00e9 apyr\u00e9tique, plaies colles..."}], "confidence": 0.5482326997794813, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Subf\u00e9brile\" (type: complication, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.02. Preuve textuelle: \"Risque infectieux: subf\u00e9brile \u00e0 37.9\u00b0\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "O11", "label": "Pr\u00e9\u00e9clampsie surajout\u00e9e \u00e0 une hypertension chronique", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 20331, "end": 20383}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (1", "context": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G ..."}], "confidence": 0.5393008192524322, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Hypertension art\u00e9rielle\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: chronique). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (1\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "D89.3", "label": "Syndrome de restauration immunitaire", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 40320, "end": 40381}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) S", "context": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -..."}], "confidence": 0.54995115995116, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Insuffisance r\u00e9nale (estimation du DFG)\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.02. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) S\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "F50.2", "label": "Boulimie [bulimia nervosa]", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 61217, "end": 61247}, "text": "Glucose 6,7 mmol/l 10,9 mmol/l", "context": "...8,4 % 5,6 %\nMonocytes (#) 0,74 10.9/l 0,87 10.9/l\nGlucose 6,7 mmol/l 10,9 mmol/l\nALAT 33 U/l 26 U/l\nFormule sanguine r\u00e9alis\u00e9e sur ..."}], "confidence": 0.5512877583465818, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Hyperglyc\u00e9mie\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Glucose 6,7 mmol/l 10,9 mmol/l\" (document: 15_23096332_DOC004). S\u00e9lectionn\u00e9 comme DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "J06.0", "label": "Laryngopharyngite aig\u00fce", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 60584, "end": 60605}, "text": "CRP 257 mg/l 313 mg/l", "context": "...mmol/l 96 mmol/l\nCr\u00e9atinine 116 \u00b5mol/l 138 \u00b5mol/l\nCRP 257 mg/l 313 mg/l\nCompte rendu Bact\u00e9riologie Bact230520080407-1.pdf..."}], "confidence": 0.5517672507030067, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Inflammation ou infection (CRP \u00e9lev\u00e9e)\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"CRP 257 mg/l 313 mg/l\" (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": "HMCC003", "label": "Chol\u00e9cystogastrostomie ou chol\u00e9cystoduod\u00e9nostomie, par c\u0153lioscopie", "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": 0.5529065833983867, "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: 0.03. Preuve textuelle: \"CHOLECYSTECTOMIE PAR LAPAROSCOPIE\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "HNEA740", "label": "Transplantation d\u2019\u00eelots pancr\u00e9atiques par dispositif implant\u00e9, par laparotomie", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 591}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n    ..."}], "confidence": 0.5509052031361369, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"cr\u00e9ation d\u2019un pneumop\u00e9ritoine par open laparoscopie p\u00e9ri-ombilicale\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "GLLD013", "label": "Ventilation spontan\u00e9e sur trach\u00e9otomie au cours du sevrage d'une ventilation m\u00e9canique, par 24 heures", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 620}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docte", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n    Anesth\u00e9siste(s) Docteur L. KA..."}], "confidence": 0.5518570183086313, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"introduction d\u2019un trocart de 10 mm pour insufflation du pneumop\u00e9ritoine jusqu\u2019\u00e0 12 mm de Hg\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docte\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "YYYY325", "label": "Irradiation de 300 cm\u00b2 et plus en champs fixes par acc\u00e9l\u00e9rateur par fraction de 25 Grays pour les faisceaux de 0,5 \u00e0 4,9 MeV, incluant 3 volumes", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 585}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du ", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER..."}], "confidence": 0.5524217621569572, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"introduction de trois trocarts de 5 mm\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du \" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "BGFA011", "label": "Vitrectomie par scl\u00e9rotomie post\u00e9rieure, avec extraction du cristallin", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 597}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 :", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n    Anesth..."}], "confidence": 0.5510334403929719, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"abord et dissection du triangle de Callot et de l\u2019infundibulum v\u00e9siculaire\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 :\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "JKDA001", "label": "Hyst\u00e9ropexie post\u00e9rieure [Promontofixation] avec cervicocystopexie directe au ligament pectin\u00e9al [de Cooper], par laparotomie", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 619}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Doct", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n    Anesth\u00e9siste(s) Docteur L. K..."}], "confidence": 0.5502271018198226, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"individualisation du canal cystique et de l\u2019art\u00e8re cystique\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Doct\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "AFFA002", "label": "Ex\u00e9r\u00e8se de tumeur en sablier extracanalaire et intracanalaire vert\u00e9brale avec reconstruction vert\u00e9brale, par abord post\u00e9rieur ou post\u00e9rolat\u00e9ral", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 619}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Doct", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n    Anesth\u00e9siste(s) Docteur L. K..."}], "confidence": 0.5503396851698426, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"section du canal cystique apr\u00e8s contr\u00f4le par deux clips (HEMOLOCK 5)\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Doct\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "HMFA006", "label": "Chol\u00e9cystectomie par c\u0153lioscopie, avec chol\u00e9dochoduod\u00e9nostomie par laparotomie", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 551}, "text": "    Diagnostic : chol\u00e9cystit", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n  ..."}], "confidence": 0.5529032258064517, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"chol\u00e9cystectomie r\u00e9trograde\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"    Diagnostic : chol\u00e9cystit\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "GELE008", "label": "Pose d'une endoproth\u00e8se trach\u00e9obronchique, par endoscopie", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 587}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n..."}], "confidence": 0.5499821746880571, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"ext\u00e9riorisation de la v\u00e9sicule dans un endosac\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.02. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "HESE002", "label": "H\u00e9mostase de l\u00e9sion de l'\u0153sophage, de l'estomac et/ou du duod\u00e9num sans laser, par \u0153so-gastro-duod\u00e9noscopie", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 608}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9ra", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n    Anesth\u00e9siste(s) D..."}], "confidence": 0.5515149040424663, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"v\u00e9rification du lit v\u00e9siculaire et h\u00e9mostase compl\u00e9mentaire ponctuelle\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9ra\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "DEQP003", "label": "\u00c9lectrocardiographie sur au moins 12 d\u00e9rivations", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 611}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateu", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n    Anesth\u00e9siste(s) Doct..."}], "confidence": 0.5520307553143374, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"mise en place d\u2019un drain Jackson-Pratt au niveau du lit v\u00e9siculaire\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateu\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "NZHH004", "label": "Ponction ou cytoponction d'une articulation du membre inf\u00e9rieur, par voie transcutan\u00e9e avec guidage radiologique", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 640}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n   ", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n    Anesth\u00e9siste(s) Docteur L. KARAM \n    Aide(s) : L..."}], "confidence": 0.5500373412994772, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"v\u00e9rification de l\u2019art\u00e8re et du canal cystique clipp\u00e9s\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n   \" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "BGNP006", "label": "Destruction de l\u00e9sion chorior\u00e9tinienne par photocoagulation transscl\u00e9rale", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 2207, "end": 2257}, "text": "Ablation de tous les trocarts sous contr\u00f4le la vue", "context": "...bonne h\u00e9mostase et l'absence de fuit e bilia \n    Ablation de tous les trocarts sous contr\u00f4le la vue  ce qui permet de v\u00e9rifier l'absence de saignemen..."}], "confidence": 0.5503159252095422, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"ablation des trocarts sous contr\u00f4le de la vue\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Ablation de tous les trocarts sous contr\u00f4le la vue\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "LJMA005", "label": "Plastie de malformation sternocostale, sans ost\u00e9osynth\u00e8se", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 2742, "end": 2788}, "text": "Exsufflation de l'ensemble du pneumop\u00e9ritoine.", "context": "...____ \nCompte rendu op\u00e9ratoire \n    ponction. \n    Exsufflation de l'ensemble du pneumop\u00e9ritoine. \n    Fermeture apon\u00e9vrotique des orifices trocart..."}], "confidence": 0.5497142857142858, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"exsufflation du pneumop\u00e9ritoine\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.02. Preuve textuelle: \"Exsufflation de l'ensemble du pneumop\u00e9ritoine.\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "DBBF198", "label": "R\u00e9tr\u00e9cissement de l\u2019orifice atrioventriculaire  gauche par dispositif par voie veineuse  transcutan\u00e9e et voie transseptale  avec guidage par \u00e9chographie-doppler par voie trans\u0153sophagienne", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 2794, "end": 2878}, "text": "Fermeture apon\u00e9vrotique des orifices trocart de 10 mm par un point en X de Vicryl 0.", "context": "...sufflation de l'ensemble du pneumop\u00e9ritoine. \n    Fermeture apon\u00e9vrotique des orifices trocart de 10 mm par un point en X de Vicryl 0. \n    Fermeture cutan\u00e9e par fils r\u00e9sorbables \n    ..."}], "confidence": 0.5511888111888112, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"fermeture apon\u00e9vrotique des orifices trocart de 10 mm par un point en X de Vicryl 0\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Fermeture apon\u00e9vrotique des orifices trocart de 10 mm par un point en X de Vicryl 0.\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "HJJA001", "label": "Drainage d'une fistule rectovaginale acquise", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 2884, "end": 2922}, "text": "Fermeture cutan\u00e9e par fils r\u00e9sorbables", "context": "...cart de 10 mm par un point en X de Vicryl 0. \n    Fermeture cutan\u00e9e par fils r\u00e9sorbables \n    Drainage : oui \n    Bact\u00e9riologie : oui \n   ..."}], "confidence": 0.5484247866090235, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"fermeture cutan\u00e9e par fils r\u00e9sorbables\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.02. Preuve textuelle: \"Fermeture cutan\u00e9e par fils r\u00e9sorbables\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "DHNF005", "label": "Fibrinolyse in situ de la veine cave sup\u00e9rieure, par voie veineuse transcutan\u00e9e", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC002", "span": {"start": 523, "end": 587}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n..."}], "confidence": 0.550894660894661, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"ext\u00e9riorisation de la v\u00e9sicule dans un endosac via trocart de 10 mm\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18\" (document: 15_23096332_DOC002). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "DGLF002", "label": "Pose d'endoproth\u00e8se couverte aorto-uniiliaque, par voie art\u00e9rielle transcutan\u00e9e", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 0, "end": 46}, "text": "N\u00b0 Finess CENTRE HOSPITALIER COTE BASQUE\n*6400", "context": "N\u00b0 Finess CENTRE HOSPITALIER COTE BASQUE\n*640000162* \u2709 13, Avenue de l'Interne J. LOEB BP 8, 641..."}], "confidence": 0.5517094017094017, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"passage aux urgences\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"N\u00b0 Finess CENTRE HOSPITALIER COTE BASQUE\n*6400\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "DGFA001", "label": "Thromboendart\u00e9riectomie du tronc de l'aorte abdominale, par laparotomie", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1307, "end": 1334}, "text": "echo faite en ville ce jour", "context": "...roit depuis 5 jours, sd inflammatoire biologique, echo faite en ville ce jour Cholecystite\nAntalgie par palier II et Ibuprofene..."}], "confidence": 0.5519509476031216, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"\u00c9chographie abdominale\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"echo faite en ville ce jour\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "YYYY108", "label": "Surveillance post op\u00e9ratoire d'un patient de chirurgie cardiaque avec CEC, niveau 1", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 1668, "end": 1705}, "text": "D\u00e9cision m\u00e9dicale Hospitalisation MCO", "context": "...icale 17/05/2023\nHeure de d\u00e9cision m\u00e9dicale 13:53\nD\u00e9cision m\u00e9dicale Hospitalisation MCO\nOrientation du patient hospitalisation dans une u..."}], "confidence": 0.5522144522144523, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"Hospitalisation en M\u00e9decine Chirurgie Obst\u00e9trique (MCO)\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"D\u00e9cision m\u00e9dicale Hospitalisation MCO\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "PAMH001", "label": "Cimentoplastie intraosseuse extrarachidienne, par voie transcutan\u00e9e avec guidage radiologique", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 9202, "end": 9222}, "text": "retour de bloc \u00e0 15h", "context": "...on ok  \nNote IDE Am\u00e9lie CAILLAUD 18/05/2023\n15:20\nretour de bloc \u00e0 15h\n- douleur peu algique\n- apyr\u00e9tique\n-constantes ok..."}], "confidence": 0.5503957075788062, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"Retour de bloc\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"retour de bloc \u00e0 15h\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "LBLD001", "label": "Pose d'un ch\u00e2ssis m\u00e9tallique support de proth\u00e8se maxillofaciale [proth\u00e8se obturatrice]", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 9473, "end": 9509}, "text": "Bloc: ce jour pr\u00e9paration patient ok", "context": "...lever fait\nNote IDE Laure BIDART 18/05/2023\n12:44 Bloc: ce jour pr\u00e9paration patient ok\nNote IDE Nahia\nOLAZCUAGA\n17/05/2023\n23:37\nChol\u00e9cy..."}], "confidence": 0.5512698412698414, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"Pr\u00e9paration du patient pour le bloc\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Bloc: ce jour pr\u00e9paration patient ok\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "AGQP006", "label": "Surveillance perop\u00e9ratoire des potentiels \u00e9voqu\u00e9s moteurs, sensoriels ou somesth\u00e9siques, pendant moins de 2 heures", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 20331, "end": 20514}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG poudre (1 mL) - Dose 1 G - sur 20 min\n- INTRAVEINEUSE Discontinu", "context": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG poudre (1 mL) - Dose 1 G - sur 20 min\n- INTRAVEINEUSE Discontinue - Toutes les 8\nHeure(s) - 1\u00e8re dose: 17/05/2023 ..."}], "confidence": 0.551031894934334, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"DESINFECTION ENVIRONNEMENT PATIENT - Matin midi go\u00fbter soir - pendant 20 Jour(s)\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG poudre (1 mL) - Dose 1 G - sur 20 min\n- INTRAVEINEUSE Discontinu\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "AHQP016", "label": "Mesure des r\u00e9flexes H et/ou T", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 20331, "end": 20491}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG poudre (1 mL) - Dose 1 G - sur 20 min\n- I", "context": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG poudre (1 mL) - Dose 1 G - sur 20 min\n- INTRAVEINEUSE Discontinue - Toutes les 8\nHeure(s) -..."}], "confidence": 0.5528008192524322, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"LEVER : AUTORISE - 2X /jour (8h 16h) - pendant 20 Jour(s)\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG poudre (1 mL) - Dose 1 G - sur 20 min\n- I\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "AHNB002", "label": "Destruction s\u00e9lective unilat\u00e9rale ou bilat\u00e9rale du nerf grand occipital [grand nerf occipital d'Arnold], par voie transcutan\u00e9e", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 40320, "end": 40442}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG pou", "context": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG poudre (1 mL) - Dose 1 G - sur 20 min\n- INTRAVEINEUSE..."}], "confidence": 0.5522716627634661, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"DESINFECTION ENVIRONNEMENT PATIENT - Matin midi go\u00fbter soir\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG pou\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "DEFA002", "label": "Ex\u00e9r\u00e8se ou destruction de foyer arythmog\u00e8ne ou de faisceau cardionecteur pour tachycardie supraventriculaire, par thoracotomie avec CEC", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 40320, "end": 40419}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1", "context": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG poudre (1 mL) - Dose 1 G - sur..."}], "confidence": 0.5524038461538462, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"LEVER : AUTORISE - 2X /jour (8h 16h)\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "AHQB015", "label": "\u00c9lectromyographie de fibre unique, par \u00e9lectrode aiguille", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 40320, "end": 40415}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME P", "context": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG poudre (1 mL) - Dose 1 G -..."}], "confidence": 0.5507775768535262, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"LIT : REFECTION COMPLETE - \u00e0 08h\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME P\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "JQJB001", "label": "\u00c9vacuation de collection d'un organe f\u0153tal", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 40320, "end": 40428}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR IN", "context": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG poudre (1 mL) - Dose 1 G - sur 20 min\n-..."}], "confidence": 0.5465573770491803, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"REPAS : INSTALLATION - Matin midi go\u00fbter soir\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.02. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR IN\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "AJNH005", "label": "Destruction chimique du ganglion pt\u00e9rygopalatin, par voie transcutan\u00e9e avec guidage radiologique", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 40320, "end": 40410}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAX", "context": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ -\n1000MG poudre (1 mL) - Dose ..."}], "confidence": 0.5504120089428298, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"TOILETTE : AUTONOME - \u00e0 08h\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.03. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAX\" (document: 15_23096332_DOC004). 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). 249 faits cliniques ont \u00e9t\u00e9 extraits et analys\u00e9s. Diagnostic Principal (DP): F05.0 - D\u00e9lirium non surajout\u00e9 \u00e0 une d\u00e9mence, ainsi d\u00e9crit (confiance: 0.55). Diagnostic Reli\u00e9 (DR): K80 - Chol\u00e9lithiase (confiance: 0.55). 25 Diagnostic(s) Associ\u00e9(s) Significatif(s) (DAS) propos\u00e9(s). 29 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": "veto", "dim_errors": [{"error_type": "act_without_evidence", "message": "Acte CCAM DEQP003 propos\u00e9 sans preuve explicite d'acte. Fait source de type: traitement", "affected_codes": ["DEQP003"], "severity": "bloquant"}, {"error_type": "act_without_evidence", "message": "Acte CCAM AHQP016 propos\u00e9 sans preuve explicite d'acte. Fait source de type: examen", "affected_codes": ["AHQP016"], "severity": "bloquant"}, {"error_type": "act_without_evidence", "message": "Acte CCAM DEFA002 propos\u00e9 sans preuve explicite d'acte. Fait source de type: examen", "affected_codes": ["DEFA002"], "severity": "bloquant"}], "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 56 code(s): DP=F05.0, DR=K80, 25 DAS, 29 CCAM. 3 erreur(s) sensible(s) DIM d\u00e9tect\u00e9e(s):   - [BLOQUANT] act_without_evidence: Acte CCAM DEQP003 propos\u00e9 sans preuve explicite d'acte. Fait source de type: traitement   - [BLOQUANT] act_without_evidence: Acte CCAM AHQP016 propos\u00e9 sans preuve explicite d'acte. Fait source de type: examen   - [BLOQUANT] act_without_evidence: Acte CCAM DEFA002 propos\u00e9 sans preuve explicite d'acte. Fait source de type: examen Aucune contradiction d\u00e9tect\u00e9e. D\u00e9cision du V\u00e9rificateur: REJET\u00c9E (VETO) - Contradictions bloquantes d\u00e9tect\u00e9es, arbitrage TIM requis. La proposition contient des erreurs critiques qui n\u00e9cessitent un arbitrage TIM avant validation."}}


record_id: audit_160a31141180627b
timestamp: 2026-02-12 00:57:53.999252
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 00:57:54.002899
data:
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record_id: audit_1ee175c38f02f7d3
timestamp: 2026-02-12 00:58:39.936823
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: 2026-02-12 00:58:39.937778
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). 217 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."}}


# evidences

text:
  Diagnostic : cholécystite
  Compte rendu opératoire du 18/05/2023 :

created_at: 2026-02-12 00:47:39.566809
context:
      Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docteur R. DIDAILLER 
      Anesthés...


text: La vésicule est d’aspect nécrotique avec perforation cloisonnée.
created_at: 2026-02-12 00:47:39.572280
context:
  ...aparoscopie 
      Constatations opératoires : 
      La vésicule est d’aspect nécrotique avec perforation cloisonnée. Pédiculite. 
      Le foie est d’aspect fibreux 
    ...


text: Pédiculite.
created_at: 2026-02-12 00:47:39.574053
context:
  ... d’aspect nécrotique avec perforation cloisonnée. Pédiculite. 
      Le foie est d’aspect fibreux 
      Le canal c...


text: Le foie est d’aspect fibreux
created_at: 2026-02-12 00:47:39.575031
context:
  ...que avec perforation cloisonnée. Pédiculite. 
      Le foie est d’aspect fibreux 
      Le canal cystique est court 
      Cholangiogr...


text: Le canal cystique est court
created_at: 2026-02-12 00:47:39.576074
context:
  ...édiculite. 
      Le foie est d’aspect fibreux 
      Le canal cystique est court 
      Cholangiographie per-opératoire : Essai mais...


text: Présence de calcul
created_at: 2026-02-12 00:47:39.576871
context:
  ...men anatomopa thologique : Aspect macroscopique : Présence de calcul 
      perforation de la vésicule, Absence d’un can...


text: Le lit vésiculaire est complètement purulent.
created_at: 2026-02-12 00:47:39.578728
context:
  ...tion d'h émostase complémentaire ponctuelle. 
      Le lit vésiculaire est complètement purulent. On me ttra donc un Jackson-Pratt au niveau du lit...


text: Mode d'entrée Autres admissions urgentes
created_at: 2026-02-12 00:47:39.580007
context:
  ...Médicalisation du transport Aucune médicalisation
  Mode d'entrée Autres admissions urgentes
  Date d'orientation 17/05/2023
  Heure d'orientation...


text: douleur hypochondre droit depuis 5 jours
created_at: 2026-02-12 00:47:39.582534
context:
  ...rise en charge Douleur abdominale
  Observ. IDE Urg
  douleur hypochondre droit depuis 5 jours, sd inflammatoire biologique, echo faite en ville...


text: sd inflammatoire biologique
created_at: 2026-02-12 00:47:39.583168
context:
  ...IDE Urg
  douleur hypochondre droit depuis 5 jours, sd inflammatoire biologique, echo faite en ville ce jour Cholecystite
  Antalgi...


text: echo faite en ville ce jour Cholecystite
created_at: 2026-02-12 00:47:39.584100
context:
  ...roit depuis 5 jours, sd inflammatoire biologique, echo faite en ville ce jour Cholecystite
  Antalgie par palier II et Ibuprofene
  ATCD DNID
  Mé...


text: ATCD DNID
created_at: 2026-02-12 00:47:39.584741
context:
  ...Cholecystite
  Antalgie par palier II et Ibuprofene
  ATCD DNID
  Médecin de la prise en charge médicale LARRIEU--N...


text: Principal actif K81.9 Cholécystite, sans précision [CMA2] 17/05/2023 14:54
created_at: 2026-02-12 00:47:39.585608
context:
  Diagnostic aux urgences
  Type Etat Code Date
  Principal actif K81.9 Cholécystite, sans précision [CMA2] 17/05/2023 14:54


text: Poids: 90 kg - IMC: 30.071
created_at: 2026-02-12 00:47:39.586487
context:
  ...ISCERALE - CHIRURGIE VISC.A2 ) - Taille: 173 cm - Poids: 90 kg - IMC: 30.071
  Le 20/05/2023 14:40 Page 1 de 24


text: pedicultite
created_at: 2026-02-12 00:47:39.587280
context:
  ...lécystite gangreneuse avec perforation cloisonnée
  pedicultite
  2hemoclock de 5 sur l'artère hemlock de 5 sur le ...


text: Douleur: EVS 2/4 à 23h30 -> ATG1 + ATS -> soulagé
created_at: 2026-02-12 00:47:39.589608
context:
  .../05/2023
  23:25
  J1 Cholécystectomie
  Surv POst Op:
  -Douleur: EVS 2/4 à 23h30 -> ATG1 + ATS -> soulagé
  Constantes stables et dans les normes
  -Risque inf...


text: Risque infectieux: subfébrile à 37.9°
created_at: 2026-02-12 00:47:39.590215
context:
  ...-> soulagé
  Constantes stables et dans les normes
  -Risque infectieux: subfébrile à 37.9° -> découvert recontrolé apyrétique, plaies colles...


text: Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (1
created_at: 2026-02-12 00:47:39.591101
context:
  Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAXIME PAN 1 G ...


text: Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) S
created_at: 2026-02-12 00:47:39.591811
context:
  Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAXIME PAN 1 G PDR INJ -...


text: Glucose 6,7 mmol/l 10,9 mmol/l
created_at: 2026-02-12 00:47:39.592576
context:
  ...8,4 % 5,6 %
  Monocytes (#) 0,74 10.9/l 0,87 10.9/l
  Glucose 6,7 mmol/l 10,9 mmol/l
  ALAT 33 U/l 26 U/l
  Formule sanguine réalisée sur ...


text: CRP 257 mg/l 313 mg/l
created_at: 2026-02-12 00:47:39.593508
context:
  ...mmol/l 96 mmol/l
  Créatinine 116 µmol/l 138 µmol/l
  CRP 257 mg/l 313 mg/l
  Compte rendu Bactériologie Bact230520080407-1.pdf...


text:
  Diagnostic : cholécystite
  Compte rendu opératoire du 18/05/

created_at: 2026-02-12 00:47:39.595009
context:
      Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docteur R. DIDAILLER 
      ...


text:
  Diagnostic : cholécystite
  Compte rendu opératoire du 18/05/2023 :
  Opérateur : Docte

created_at: 2026-02-12 00:47:39.595619
context:
      Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docteur R. DIDAILLER 
      Anesthésiste(s) Docteur L. KA...


text:
  Diagnostic : cholécystite
  Compte rendu opératoire du

created_at: 2026-02-12 00:47:39.596212
context:
      Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docteur R. DIDAILLER...


text:
  Diagnostic : cholécystite
  Compte rendu opératoire du 18/05/2023 :

created_at: 2026-02-12 00:47:39.596755
context:
      Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docteur R. DIDAILLER 
      Anesth...


text:
  Diagnostic : cholécystite
  Compte rendu opératoire du 18/05/2023 :
  Opérateur : Doct

created_at: 2026-02-12 00:47:39.597371
context:
      Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docteur R. DIDAILLER 
      Anesthésiste(s) Docteur L. K...


text:
  Diagnostic : cholécystite
  Compte rendu opératoire du 18

created_at: 2026-02-12 00:47:39.599287
context:
      Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docteur R. DIDAILLER 
  ...


text:
  Diagnostic : cholécystite
  Compte rendu opératoire du 18/05/2023 :
  Opéra

created_at: 2026-02-12 00:47:39.599937
context:
      Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docteur R. DIDAILLER 
      Anesthésiste(s) D...


text:
  Diagnostic : cholécystite
  Compte rendu opératoire du 18/05/2023 :
  Opérateu

created_at: 2026-02-12 00:47:39.600372
context:
      Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docteur R. DIDAILLER 
      Anesthésiste(s) Doct...


created_at: 2026-02-12 00:47:39.600768
text:
      Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docteur R. DIDAILLER 
     

context:
      Diagnostic : cholécystite 
      Compte rendu opératoire du 18/05/2023 : 
      Opérateur : Docteur R. DIDAILLER 
      Anesthésiste(s) Docteur L. KARAM 
      Aide(s) : L...


text: Ablation de tous les trocarts sous contrôle la vue
created_at: 2026-02-12 00:47:39.601146
context:
  ...bonne hémostase et l'absence de fuit e bilia 
      Ablation de tous les trocarts sous contrôle la vue  ce qui permet de vérifier l'absence de saignemen...


text: Exsufflation de l'ensemble du pneumopéritoine.
created_at: 2026-02-12 00:47:39.601524
context:
  ...____ 
  Compte rendu opératoire 
      ponction. 
      Exsufflation de l'ensemble du pneumopéritoine. 
      Fermeture aponévrotique des orifices trocart...


text: Fermeture aponévrotique des orifices trocart de 10 mm par un point en X de Vicryl 0.
created_at: 2026-02-12 00:47:39.601888
context:
  ...sufflation de l'ensemble du pneumopéritoine. 
      Fermeture aponévrotique des orifices trocart de 10 mm par un point en X de Vicryl 0. 
      Fermeture cutanée par fils résorbables 
      ...


text: Fermeture cutanée par fils résorbables
created_at: 2026-02-12 00:47:39.602251
context:
  ...cart de 10 mm par un point en X de Vicryl 0. 
      Fermeture cutanée par fils résorbables 
      Drainage : oui 
      Bactériologie : oui 
     ...


text: echo faite en ville ce jour
created_at: 2026-02-12 00:47:39.603475
context:
  ...roit depuis 5 jours, sd inflammatoire biologique, echo faite en ville ce jour Cholecystite
  Antalgie par palier II et Ibuprofene...


text: Décision médicale Hospitalisation MCO
created_at: 2026-02-12 00:47:39.603881
context:
  ...icale 17/05/2023
  Heure de décision médicale 13:53
  Décision médicale Hospitalisation MCO
  Orientation du patient hospitalisation dans une u...


text: retour de bloc à 15h
created_at: 2026-02-12 00:47:39.604266
context:
  ...on ok  
  Note IDE Amélie CAILLAUD 18/05/2023
  15:20
  retour de bloc à 15h
  - douleur peu algique
  - apyrétique
  -constantes ok...


text: Bloc: ce jour préparation patient ok
created_at: 2026-02-12 00:47:39.604653
context:
  ...lever fait
  Note IDE Laure BIDART 18/05/2023
  12:44 Bloc: ce jour préparation patient ok
  Note IDE Nahia
  OLAZCUAGA
  17/05/2023
  23:37
  Cholécy...


created_at: 2026-02-12 00:47:39.605041
text:
  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

context:
  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 Discontinue - Toutes les 8
  Heure(s) - 1ère dose: 17/05/2023 ...


created_at: 2026-02-12 00:47:39.605469
text:
  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

context:
  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 Discontinue - Toutes les 8
  Heure(s) -...


created_at: 2026-02-12 00:47:39.605851
text:
  Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAXIME PAN 1 G PDR INJ -
  1000MG pou

context:
  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...


text:
  Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAXIME PAN 1

created_at: 2026-02-12 00:47:39.606218
context:
  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...


text:
  Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAXIME P

created_at: 2026-02-12 00:47:39.606583
context:
  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 -...


created_at: 2026-02-12 00:47:39.606937
text:
  Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAXIME PAN 1 G PDR IN

context:
  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
  -...


text:
  Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)
  Signé — CEFOTAX

created_at: 2026-02-12 00:47:39.607194
context:
  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 ...


