# audit_records

record_id: audit_b29cccedeb6f86a9
timestamp: 2026-02-12 00:09:52.392164
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 00:09:52.392944
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": [], "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). 268 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."}}


record_id: audit_271fda809f837fbc
timestamp: 2026-02-12 00:16:57.465834
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 00:16:57.466684
data:
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record_id: audit_1067ce89f4065d85
timestamp: 2026-02-12 00:17:31.619634
event_type: coding
actor: codeur
model_name: mock-llm
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created_at: 2026-02-12 00:17:31.620572
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record_id: audit_31357b8926ae1da0
timestamp: 2026-02-12 00:17:31.623720
event_type: verification
actor: verificateur
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
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created_at: 2026-02-12 00:17:31.624135
data:
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record_id: audit_ffb44e76a37027c5
timestamp: 2026-02-12 00:17:31.840333
event_type: coding
actor: system
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: 2026-02-12 00:17:31.841124
data:
  {"proposal": {"dp": {"code": "T09.1", "label": "Plaie ouverte du tronc, niveau non pr\u00e9cis\u00e9", "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": 0.54, "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: 0.00. 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": 0.6378864550590515, "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: 0.24. 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": "B08.4", "label": "Stomatite v\u00e9siculaire avec exanth\u00e8me, due \u00e0 un ent\u00e9rovirus", "type": "das", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 0, "end": 68}, "text": "CROp Epi -  BERNACHOT-FAURE, CHRISTIAN \n____________________________", "context": "CROp Epi -  BERNACHOT-FAURE, CHRISTIAN \n___________________________________________________ __________________________..."}], "confidence": 0.252, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"pathologie v\u00e9siculaire n\u00e9cessitant une chol\u00e9cystectomie\" (type: diagnostic, certitude: suspect\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"CROp Epi -  BERNACHOT-FAURE, CHRISTIAN \n____________________________\" (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": "T30", "label": "Brulure et corrosion, partie du corps non pr\u00e9cis\u00e9e", "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": 0.54, "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: 0.00. 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": 0.54, "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: 0.00. 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": "S34.3", "label": "L\u00e9sion traumatique de la queue de cheval", "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": 0.54, "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: 0.00. 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": "J31", "label": "Rhinite, rhinopharyngite et pharyngite chroniques", "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": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"lit v\u00e9siculaire purulent\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. 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": "UNKNOWN", "label": "R\u00e9sultat de la premi\u00e8re pes\u00e9e du foetus ou du nouveau-n\u00e9 effectu\u00e9e apr\u00e8s la naissance. \n3.4. Poids f", "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": 0.54, "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: 0.00. 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": "Q27.4", "label": "Phl\u00e9bectasie cong\u00e9nitale", "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": 0.54, "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: 0.00. 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": "T82.7", "label": "Infection et r\u00e9action inflammatoire dues \u00e0 d'autres proth\u00e8ses, implants et greffes", "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": 0.54, "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: 0.00. 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": "E66.2", "label": "Ob\u00e9sit\u00e9 (extr\u00eame) avec hypoventilation alv\u00e9olaire", "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": 0.54, "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: 0.00. 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": 0.54, "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: 0.00. 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": "Z46", "label": "Mise en place et ajustement d'autres appareils", "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": 0.54, "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: 0.00. 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": "X46", "label": "Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations", "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": 0.9400000000000001, "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: 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 DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "K40.9", "label": "Hernie inguinale, unilat\u00e9rale ou sans pr\u00e9cision, sans occlusion ni gangr\u00e8ne", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 5558, "end": 5610}, "text": "chol\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e", "context": "...d'\u00e9volution DR. Romain\nDIDAILLER\n18/05/2023\n12:49\nchol\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e\npedicultite\n2hemoclock de 5 sur l'art\u00e8re hemlock ..."}], "confidence": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"chol\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"chol\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e\" (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": "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"}, {"code": "Z36.2", "label": "Autres d\u00e9pistages pr\u00e9natals par amniocent\u00e8se", "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": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Subf\u00e9brile (37.9\u00b0)\" (type: complication, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. 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": "Z64.3", "label": "Recherche et acceptation d'interventions comportementales et psychologiques", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 8937, "end": 8947}, "text": "Apyr\u00e9tique", "context": "...tieux: subf\u00e9brile \u00e0 37.9\u00b0 -> d\u00e9couvert recontrol\u00e9 apyr\u00e9tique, plaies colles propres,\nredon en aspi 70cc s\u00e9ro s..."}], "confidence": 0.6795085215568543, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Apyr\u00e9tique\" (type: complication, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.35. Preuve textuelle: \"Apyr\u00e9tique\" (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": "A95.1", "label": "Fi\u00e8vre jaune citadine", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 9070, "end": 9089}, "text": "pas de vomissements", "context": "...opre\n-Digestif: G+ S- bien tol\u00e9r\u00e9 pas de naus\u00e9es, pas de vomissements, pas de rots CY ok\n-Endocrino: glyc\u00e9mie correcte\n..."}], "confidence": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Pas de vomissements\" (type: complication, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"pas de vomissements\" (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": "N17", "label": "Insuffisance r\u00e9nale aig\u00fce", "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": 0.24569999999999997, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Insuffisance r\u00e9nale chronique suspect\u00e9e (Estimation du DFG CKD-EPI)\" (type: diagnostic, certitude: suspect\u00e9, temporalit\u00e9: chronique). Score de similarit\u00e9 RAG: 0.00. 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": "E78", "label": "Anomalies du m\u00e9tabolisme des lipoprot\u00e9ines et autres lipid\u00e9mies", "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": 0.9400000000000001, "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: 1.00. 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": "O08.1", "label": "H\u00e9morragie retard\u00e9e ou s\u00e9v\u00e8re cons\u00e9cutive \u00e0 un avortement, une grossesse extra-", "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": 0.2713187019228935, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Inflammation ou infection suspect\u00e9e\" (type: diagnostic, certitude: suspect\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.07. 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"}, {"code": "A79", "label": "Autres rickettsioses", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 64225, "end": 64231}, "text": "fi\u00e8vre", "context": "... en cas d'\u00e9volution non pleinement satisfaisante (fi\u00e8vre, douleur\npost-op\u00e9ratoire r\u00e9sistante aux traitemen..."}], "confidence": 0.5319999999999999, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"fi\u00e8vre\" (type: complication, certitude: suspect\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"fi\u00e8vre\" (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": 61618, "end": 61687}, "text": "Examen direct N\u00e9gatif\nLeucocytes 8,79 10.9/l 14 /mm3 15,54 10.9/l\nNat", "context": "Examen direct N\u00e9gatif\nLeucocytes 8,79 10.9/l 14 /mm3 15,54 10.9/l\nNature du pr\u00e9l\u00e8vement Liquide d'ascite\nR\u00e9sultat Autom..."}], "confidence": 0.252, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"douleur post-op\u00e9ratoire r\u00e9sistante aux traitements m\u00e9dicaux habituels\" (type: complication, certitude: suspect\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"Examen direct N\u00e9gatif\nLeucocytes 8,79 10.9/l 14 /mm3 15,54 10.9/l\nNat\" (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). 273 faits cliniques ont \u00e9t\u00e9 extraits et analys\u00e9s. Diagnostic Principal (DP): T09.1 - Plaie ouverte du tronc, niveau non pr\u00e9cis\u00e9 (confiance: 0.54). Diagnostic Reli\u00e9 (DR): K80 - Chol\u00e9lithiase (confiance: 0.64). 22 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": "review", "dim_errors": [{"error_type": "dp_das_inversion", "message": "Possible inversion DP/DAS: DAS X46 (confiance: 0.94) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)", "affected_codes": ["T09.1", "X46"], "severity": "a_revoir"}, {"error_type": "dp_das_inversion", "message": "Possible inversion DP/DAS: DAS V39.6 (confiance: 0.78) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)", "affected_codes": ["T09.1", "V39.6"], "severity": "a_revoir"}, {"error_type": "dp_das_inversion", "message": "Possible inversion DP/DAS: DAS Z64.3 (confiance: 0.68) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)", "affected_codes": ["T09.1", "Z64.3"], "severity": "a_revoir"}, {"error_type": "dp_das_inversion", "message": "Possible inversion DP/DAS: DAS E78 (confiance: 0.94) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)", "affected_codes": ["T09.1", "E78"], "severity": "a_revoir"}], "contradictions": [], "alternatives": [{"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": "Alternative au DP T09.1: 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: 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 DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}], "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 25 code(s): DP=T09.1, DR=K80, 22 DAS, 1 CCAM. 4 erreur(s) sensible(s) DIM d\u00e9tect\u00e9e(s):   - [A_REVOIR] dp_das_inversion: Possible inversion DP/DAS: DAS X46 (confiance: 0.94) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)   - [A_REVOIR] dp_das_inversion: Possible inversion DP/DAS: DAS V39.6 (confiance: 0.78) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)   - [A_REVOIR] dp_das_inversion: Possible inversion DP/DAS: DAS Z64.3 (confiance: 0.68) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)   - [A_REVOIR] dp_das_inversion: Possible inversion DP/DAS: DAS E78 (confiance: 0.94) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54) Aucune contradiction d\u00e9tect\u00e9e. 1 alternative(s) sugg\u00e9r\u00e9e(s):   - X46 (dp): Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations (confiance: 0.94) D\u00e9cision du V\u00e9rificateur: \u00c0 REVOIR - Contradictions non-bloquantes d\u00e9tect\u00e9es, v\u00e9rification TIM recommand\u00e9e. La proposition n\u00e9cessite une v\u00e9rification TIM pour r\u00e9soudre les contradictions non-bloquantes."}}


record_id: audit_14db6509d45f3e65
timestamp: 2026-02-12 00:26:24.867151
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 00:26:24.867913
data:
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record_id: audit_dec8db7936fc049a
timestamp: 2026-02-12 00:27:00.592746
event_type: coding
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
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created_at: 2026-02-12 00:27:00.593513
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": [], "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). 303 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."}}


record_id: audit_3e02a4f63cfa5638
timestamp: 2026-02-12 00:29:46.677903
event_type: import
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
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created_at: 2026-02-12 00:29:46.678844
data:
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record_id: audit_f67f61c9bffe2cb9
timestamp: 2026-02-12 00:30:27.651211
event_type: coding
actor: codeur
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
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created_at: 2026-02-12 00:30:27.652190
data:
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record_id: audit_e69d1fa01230c0ad
timestamp: 2026-02-12 00:30:27.656716
event_type: verification
actor: verificateur
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
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inference_params: {"temperature": 0.0, "top_p": 1.0, "max_tokens": 2048}
created_at: 2026-02-12 00:30:27.657192
data:
  {"decision": "review", "dim_errors_count": 1, "dim_errors": [{"error_type": "dp_das_inversion", "severity": "a_revoir", "affected_codes_count": 2}], "contradictions_count": 0, "alternatives_count": 1, "reasoning_length": 888}


record_id: audit_cbb291df4ee429a5
timestamp: 2026-02-12 00:30:27.843966
event_type: coding
actor: system
model_name: mock-llm
model_digest: 6cd57cf75f60cbc083c80b158c75f4e5fe1ba2a0d5dfb8266d9c361f988ed12d
prompt_version: codeur=codeur-1.0.0,verificateur=verificateur-1.0.0
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rules_hash: 92521fc3cbd964bdc9f584a991b89fddaa5754ed1cc96d6d42445338669c1305
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created_at: 2026-02-12 00:30:27.844757
data:
  {"proposal": {"dp": {"code": "T09.1", "label": "Plaie ouverte du tronc, niveau non pr\u00e9cis\u00e9", "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": 0.54, "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: 0.00. 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": 0.6378864550590515, "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: 0.24. 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": "T30", "label": "Brulure et corrosion, partie du corps non pr\u00e9cis\u00e9e", "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": 0.54, "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: 0.00. 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": 0.54, "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: 0.00. 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": "S34.3", "label": "L\u00e9sion traumatique de la queue de cheval", "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": 0.54, "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: 0.00. 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": "J31", "label": "Rhinite, rhinopharyngite et pharyngite chroniques", "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": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"lit v\u00e9siculaire purulent\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. 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": "UNKNOWN", "label": "R\u00e9sultat de la premi\u00e8re pes\u00e9e du foetus ou du nouveau-n\u00e9 effectu\u00e9e apr\u00e8s la naissance. \n3.4. Poids f", "type": "das", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 565}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte ", "context": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : ..."}], "confidence": 0.54, "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: 0.00. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte \" (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": "Q27.4", "label": "Phl\u00e9bectasie cong\u00e9nitale", "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": 0.54, "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: 0.00. 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": "T82.7", "label": "Infection et r\u00e9action inflammatoire dues \u00e0 d'autres proth\u00e8ses, implants et greffes", "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": 0.54, "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: 0.00. 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": "E66.2", "label": "Ob\u00e9sit\u00e9 (extr\u00eame) avec hypoventilation alv\u00e9olaire", "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": 0.54, "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: 0.00. 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": 0.54, "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: 0.00. 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": "Z46", "label": "Mise en place et ajustement d'autres appareils", "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": 0.54, "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: 0.00. 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": "X46", "label": "Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations", "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": 0.9400000000000001, "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: 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 DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "K40.9", "label": "Hernie inguinale, unilat\u00e9rale ou sans pr\u00e9cision, sans occlusion ni gangr\u00e8ne", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 5558, "end": 5610}, "text": "chol\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e", "context": "...d'\u00e9volution DR. Romain\nDIDAILLER\n18/05/2023\n12:49\nchol\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e\npedicultite\n2hemoclock de 5 sur l'art\u00e8re hemlock ..."}], "confidence": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"chol\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"chol\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e\" (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": 6065, "end": 6077}, "text": "Dyslipid\u00e9mie", "context": "...BAL\n17/05/2023\n12:51\nPatient de 73ans,\nATCDs\nDNID\nDyslipid\u00e9mie\nArthrose lombaire avec canal lombaire \u00e9troit\nTTT ..."}], "confidence": 0.5265, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Dyslipid\u00e9mie\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: chronique). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"Dyslipid\u00e9mie\" (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": "F65.3", "label": "Voyeurisme", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 6570, "end": 6585}, "text": "plut\u00f4t constip\u00e9", "context": "...ues palier II\nPas de vomissement, pas de diarrh\u00e9e plut\u00f4t constip\u00e9\nAux Urgences peu algique (mais sous antalgiques +..."}], "confidence": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Constipation\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"plut\u00f4t constip\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": "Z36.2", "label": "Autres d\u00e9pistages pr\u00e9natals par amniocent\u00e8se", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 22556, "end": 22579}, "text": "SI NAUSEES/VOMISSEMENTS", "context": "...e(s) Si besoin - D\u00e9but presc.: 18/05/2023 @\n11:53\nSI NAUSEES/VOMISSEMENTS\nKARAM Lydia\nD\u00e9but le 18/05/2023 \u00e0\n11:53\nFin le 21..."}], "confidence": 0.252, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Surveillance de naus\u00e9es/vomissements\" (type: diagnostic, certitude: suspect\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"SI NAUSEES/VOMISSEMENTS\" (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": 20331, "end": 20440}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ", "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": 0.24569999999999997, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Diab\u00e8te (surveillance glyc\u00e9mique)\" (type: diagnostic, certitude: suspect\u00e9, temporalit\u00e9: chronique). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR INJ\" (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": "I13.02", "label": "Cardion\u00e9phropathie hypertensive, avec insuffisance cardiaque (congestive), avec fraction", "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": 0.5265, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Insuffisance r\u00e9nale chronique avec DFG estim\u00e9 \u00e0 40 ml/mn/1.73 m2 puis 33 ml/mn/1.73 m2\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: chronique). Score de similarit\u00e9 RAG: 0.00. 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": "E87.4", "label": "Anomalie mixte de l'\u00e9quilibre acidobasique", "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": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Hyperglyc\u00e9mie (Glucose \u00e0 10,9 mmol/l)\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. 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": "G03", "label": "M\u00e9ningite due \u00e0 des causes autres et non pr\u00e9cis\u00e9es", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 40320, "end": 40376}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-2", "context": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR ..."}], "confidence": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Neutrophilie (Polynucl\u00e9aires neutrophiles \u00e0 13,80 10.9/l)\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-2\" (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": "F81.1", "label": "Trouble sp\u00e9cifique de l'acquisition de l'orthographe", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 61554, "end": 61576}, "text": "Culture n\u00e9gative \u00e0 48h", "context": "...,8 mmol/l 4,3 mmol/l\nLipase 77 U/l\nCulture LAS TK\nCulture n\u00e9gative \u00e0 48h\n(les bouillons seront\nincub\u00e9s pendant 15"}], "confidence": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Culture n\u00e9gative \u00e0 48h\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"Culture n\u00e9gative \u00e0 48h\" (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). 244 faits cliniques ont \u00e9t\u00e9 extraits et analys\u00e9s. Diagnostic Principal (DP): T09.1 - Plaie ouverte du tronc, niveau non pr\u00e9cis\u00e9 (confiance: 0.54). Diagnostic Reli\u00e9 (DR): K80 - Chol\u00e9lithiase (confiance: 0.64). 20 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": "review", "dim_errors": [{"error_type": "dp_das_inversion", "message": "Possible inversion DP/DAS: DAS X46 (confiance: 0.94) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)", "affected_codes": ["T09.1", "X46"], "severity": "a_revoir"}], "contradictions": [], "alternatives": [{"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": "Alternative au DP T09.1: 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: 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 DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}], "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 23 code(s): DP=T09.1, DR=K80, 20 DAS, 1 CCAM. 1 erreur(s) sensible(s) DIM d\u00e9tect\u00e9e(s):   - [A_REVOIR] dp_das_inversion: Possible inversion DP/DAS: DAS X46 (confiance: 0.94) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54) Aucune contradiction d\u00e9tect\u00e9e. 1 alternative(s) sugg\u00e9r\u00e9e(s):   - X46 (dp): Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations (confiance: 0.94) D\u00e9cision du V\u00e9rificateur: \u00c0 REVOIR - Contradictions non-bloquantes d\u00e9tect\u00e9es, v\u00e9rification TIM recommand\u00e9e. La proposition n\u00e9cessite une v\u00e9rification TIM pour r\u00e9soudre les contradictions non-bloquantes."}}


record_id: audit_2e43cfbd042ac1e6
timestamp: 2026-02-12 00:39:33.094687
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 00:39:33.095532
data:
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record_id: audit_824a314958b92f68
timestamp: 2026-02-12 00:40:01.865236
event_type: coding
actor: codeur
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"type": "das", "confidence": 0.776, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "O08.1", "label": "H\u00e9morragie retard\u00e9e ou s\u00e9v\u00e8re cons\u00e9cutive \u00e0 un avortement, une grossesse extra-", "type": "das", "confidence": 0.6786326909065247, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "S72.0", "label": "Fracture du col du f\u00e9mur", "type": "das", "confidence": 0.54, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "E13", "label": "Autres diab\u00e8tes sucr\u00e9s pr\u00e9cis\u00e9s", "type": "das", "confidence": 0.5265, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "I13.02", "label": "Cardion\u00e9phropathie hypertensive, avec insuffisance cardiaque (congestive), avec fraction", "type": "das", "confidence": 0.54, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "E78", "label": "Anomalies du m\u00e9tabolisme des lipoprot\u00e9ines et autres lipid\u00e9mies", "type": "das", "confidence": 0.9400000000000001, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "D71", "label": "Anomalies fonctionnelles des granulocytes neutrophiles", "type": "das", "confidence": 0.7532055044174195, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "F81.1", "label": "Trouble sp\u00e9cifique de l'acquisition de l'orthographe", "type": "das", "confidence": 0.54, "evidence_count": 1, "referentiel_version": "2026", "has_reasoning": true}, {"code": "HMCC003", "label": "Chol\u00e9cystogastrostomie ou chol\u00e9cystoduod\u00e9nostomie, par c\u0153lioscopie", "type": "ccam", "confidence": 0.9400000000000001, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "JLMA002", "label": "Cr\u00e9ation d'un n\u00e9ovagin par clivage interv\u00e9sicorectal, par abord p\u00e9rin\u00e9al", "type": "ccam", "confidence": 0.54, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "YYYY381", "label": "Irradiation de 300 cm\u00b2 et plus en champs fixes par acc\u00e9l\u00e9rateur par fraction de 14 Grays pour les faisceaux de 8 \u00e0 16,9 MeV, incluant 3 volumes", "type": "ccam", "confidence": 0.54, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "YYYY480", "label": "Irradiation de 300 cm\u00b2 et plus en champs fixes par acc\u00e9l\u00e9rateur par fraction de 20 Grays pour les faisceaux de 5 \u00e0 7,9 MeV, incluant 3 volumes", "type": "ccam", "confidence": 0.54, "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": 0.54, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "JKQX147", "label": "Examen cytopathologique en phase liquide [technique monocouche] de pr\u00e9l\u00e8vement [frottis] du col de l'ut\u00e9rus pour d\u00e9pistage individuel", "type": "ccam", "confidence": 0.54, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "JJPC004", "label": "Interruption unilat\u00e9rale ou bilat\u00e9rale de la perm\u00e9abilit\u00e9 des trompes ut\u00e9rines, par p\u00e9lycoscopie [culdoscopie] [c\u0153lioscopie transvaginale]", "type": "ccam", "confidence": 0.54, "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": 0.9400000000000001, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "EACA007", "label": "Exclusion d'un an\u00e9vrisme art\u00e9riel supratentoriel d'un diam\u00e8tre inf\u00e9rieur ou \u00e9gal \u00e0 20 mm, par 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\u0153so-gastro-duod\u00e9noscopie et par voie transcutan\u00e9e avec guidage \u00e9chographique et/ou radiologique", "type": "ccam", "confidence": 0.54, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "EFNF001", "label": "Fibrinolyse in situ de la veine subclavi\u00e8re et/ou de la veine brachioc\u00e9phalique, par voie veineuse transcutan\u00e9e", "type": "ccam", "confidence": 0.54, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "DASA006", "label": "Fermeture d'une rupture du septum interventriculaire cardiaque, par thoracotomie avec CEC", "type": "ccam", "confidence": 0.54, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "JDSA010", "label": "Fermeture du col de la vessie pour cystostomie cutan\u00e9e continente", "type": "ccam", "confidence": 0.54, "evidence_count": 1, "referentiel_version": "2025", "has_reasoning": true}, {"code": "HJFA014", "label": "Ex\u00e9r\u00e8se de 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record_id: audit_625769bb08e7d9ac
timestamp: 2026-02-12 00:40:01.869228
event_type: verification
actor: verificateur
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record_id: audit_d3d057eafdcee44e
timestamp: 2026-02-12 00:40:02.066895
event_type: coding
actor: system
model_name: mock-llm
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created_at: 2026-02-12 00:40:02.067835
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  {"proposal": {"dp": {"code": "T09.1", "label": "Plaie ouverte du tronc, niveau non pr\u00e9cis\u00e9", "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": 0.54, "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: 0.00. 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": 0.6378864550590515, "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: 0.24. 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": "B08.4", "label": "Stomatite v\u00e9siculaire avec exanth\u00e8me, due \u00e0 un ent\u00e9rovirus", "type": "das", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 0, "end": 68}, "text": "CROp Epi -  BERNACHOT-FAURE, CHRISTIAN \n____________________________", "context": "CROp Epi -  BERNACHOT-FAURE, CHRISTIAN \n___________________________________________________ __________________________..."}], "confidence": 0.252, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"pathologie v\u00e9siculaire n\u00e9cessitant une chol\u00e9cystectomie\" (type: diagnostic, certitude: suspect\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"CROp Epi -  BERNACHOT-FAURE, CHRISTIAN \n____________________________\" (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": "T30", "label": "Brulure et corrosion, partie du corps non pr\u00e9cis\u00e9e", "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": 0.54, "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: 0.00. 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": 0.54, "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: 0.00. 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": "S34.3", "label": "L\u00e9sion traumatique de la queue de cheval", "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": 0.54, "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: 0.00. 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": "UNKNOWN", "label": "R\u00e9sultat de la premi\u00e8re pes\u00e9e du foetus ou du nouveau-n\u00e9 effectu\u00e9e apr\u00e8s la naissance. \n3.4. Poids f", "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": 0.54, "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: 0.00. 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": "Q27.4", "label": "Phl\u00e9bectasie cong\u00e9nitale", "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": 0.54, "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: 0.00. 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": "J31", "label": "Rhinite, rhinopharyngite et pharyngite chroniques", "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": 0.54, "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: 0.00. 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": "T82.7", "label": "Infection et r\u00e9action inflammatoire dues \u00e0 d'autres proth\u00e8ses, implants et greffes", "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": 0.54, "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: 0.00. 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": "E66.2", "label": "Ob\u00e9sit\u00e9 (extr\u00eame) avec hypoventilation alv\u00e9olaire", "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": 0.54, "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: 0.00. 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": 0.54, "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: 0.00. 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": "Z46", "label": "Mise en place et ajustement d'autres appareils", "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": 0.54, "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: 0.00. 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": "X46", "label": "Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations", "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": 0.9400000000000001, "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: 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 DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}, {"code": "K40.9", "label": "Hernie inguinale, unilat\u00e9rale ou sans pr\u00e9cision, sans occlusion ni gangr\u00e8ne", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 5558, "end": 5610}, "text": "chol\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e", "context": "...d'\u00e9volution DR. Romain\nDIDAILLER\n18/05/2023\n12:49\nchol\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e\npedicultite\n2hemoclock de 5 sur l'art\u00e8re hemlock ..."}], "confidence": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"chol\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"chol\u00e9cystite gangreneuse avec perforation cloisonn\u00e9e\" (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": "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"}, {"code": "O08.1", "label": "H\u00e9morragie retard\u00e9e ou s\u00e9v\u00e8re cons\u00e9cutive \u00e0 un avortement, une grossesse extra-", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 8786, "end": 8810}, "text": "Douleur: EVS 2/4 \u00e0 23h30", "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 da..."}], "confidence": 0.6786326909065247, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Douleur post-op\u00e9ratoire\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.35. Preuve textuelle: \"Douleur: EVS 2/4 \u00e0 23h30\" (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": "S72.0", "label": "Fracture du col du f\u00e9mur", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 8894, "end": 8912}, "text": "subf\u00e9brile \u00e0 37.9\u00b0", "context": "...es stables et dans les normes\n-Risque infectieux: subf\u00e9brile \u00e0 37.9\u00b0 -> d\u00e9couvert recontrol\u00e9 apyr\u00e9tique, plaies colles..."}], "confidence": 0.54, "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: 0.00. Preuve textuelle: \"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": "E13", "label": "Autres diab\u00e8tes sucr\u00e9s pr\u00e9cis\u00e9s", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 20331, "end": 20432}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G", "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 2..."}], "confidence": 0.5265, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Diab\u00e8te (surveillance glyc\u00e9mique)\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: chronique). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G\" (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": "I13.02", "label": "Cardion\u00e9phropathie hypertensive, avec insuffisance cardiaque (congestive), avec fraction", "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": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Insuffisance r\u00e9nale chronique (estimation du DFG)\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. 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": "E78", "label": "Anomalies du m\u00e9tabolisme des lipoprot\u00e9ines et autres lipid\u00e9mies", "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": 0.9400000000000001, "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: 1.00. 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": "D71", "label": "Anomalies fonctionnelles des granulocytes neutrophiles", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 40320, "end": 40376}, "text": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-2", "context": "Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-21h) Soir (21h-07h)\nSign\u00e9 \u2014 CEFOTAXIME PAN 1 G PDR ..."}], "confidence": 0.7532055044174195, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Neutrophilie\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.53. Preuve textuelle: \"Prescriptions Matin (07h-12h) Midi (12h-16h) Soir (16h-2\" (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": "F81.1", "label": "Trouble sp\u00e9cifique de l'acquisition de l'orthographe", "type": "das", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 61554, "end": 61576}, "text": "Culture n\u00e9gative \u00e0 48h", "context": "...,8 mmol/l 4,3 mmol/l\nLipase 77 U/l\nCulture LAS TK\nCulture n\u00e9gative \u00e0 48h\n(les bouillons seront\nincub\u00e9s pendant 15"}], "confidence": 0.54, "reasoning": "Code propos\u00e9 comme Diagnostic Associ\u00e9 Significatif. Bas\u00e9 sur le fait clinique: \"Culture n\u00e9gative \u00e0 48h\" (type: diagnostic, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"Culture n\u00e9gative \u00e0 48h\" (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": 0.9400000000000001, "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"}, {"code": "JLMA002", "label": "Cr\u00e9ation d'un n\u00e9ovagin par clivage interv\u00e9sicorectal, par abord p\u00e9rin\u00e9al", "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": 0.54, "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: 0.00. 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": "YYYY381", "label": "Irradiation de 300 cm\u00b2 et plus en champs fixes par acc\u00e9l\u00e9rateur par fraction de 14 Grays pour les faisceaux de 8 \u00e0 16,9 MeV, incluant 3 volumes", "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": 0.54, "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: 0.00. 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": "YYYY480", "label": "Irradiation de 300 cm\u00b2 et plus en champs fixes par acc\u00e9l\u00e9rateur par fraction de 20 Grays pour les faisceaux de 5 \u00e0 7,9 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": 0.54, "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: 0.00. 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": 0.54, "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: 0.00. 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": "JKQX147", "label": "Examen cytopathologique en phase liquide [technique monocouche] de pr\u00e9l\u00e8vement [frottis] du col de l'ut\u00e9rus pour d\u00e9pistage individuel", "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": 0.54, "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: 0.00. 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": "JJPC004", "label": "Interruption unilat\u00e9rale ou bilat\u00e9rale de la perm\u00e9abilit\u00e9 des trompes ut\u00e9rines, par p\u00e9lycoscopie [culdoscopie] [c\u0153lioscopie transvaginale]", "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": 0.54, "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: 0.00. 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": 0.9400000000000001, "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: 1.00. Preuve textuelle: \"    Diagnostic : chol\u00e9cystit\" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "EACA007", "label": "Exclusion d'un an\u00e9vrisme art\u00e9riel supratentoriel d'un diam\u00e8tre inf\u00e9rieur ou \u00e9gal \u00e0 20 mm, par craniotomie", "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": 0.54, "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: 0.00. 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": "LAFA008", "label": "Pr\u00e9l\u00e8vement d'autogreffe osseuse par d\u00e9doublement de la vo\u00fbte du cr\u00e2ne", "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": 0.54, "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: 0.00. 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": "HBLD245", "label": "Pose d'une infrastructure coronoradiculaire [Inlay core] sous une couronne ou un pilier de bridge dentoport\u00e9s \u00e0 tarif libre", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC001", "span": {"start": 523, "end": 601}, "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\u00e9sis..."}], "confidence": 0.54, "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: 0.00. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n  \" (document: 15_23096332_DOC001). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "ACQH001", "label": "Scanographie du cr\u00e2ne et de son contenu, avec injection intrath\u00e9cale de produit de contraste [Cysternoscanner]", "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": 0.54, "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: 0.00. 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": "HMGH001", "label": "Ablation de calcul de la voie biliaire principale, par \u0153so-gastro-duod\u00e9noscopie et par voie transcutan\u00e9e avec guidage \u00e9chographique et/ou radiologique", "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": 0.54, "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: 0.00. 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": "EFNF001", "label": "Fibrinolyse in situ de la veine subclavi\u00e8re et/ou de la veine brachioc\u00e9phalique, par voie veineuse transcutan\u00e9e", "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": 0.54, "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: 0.00. 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": "DASA006", "label": "Fermeture d'une rupture du septum interventriculaire cardiaque, par thoracotomie avec CEC", "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": 0.54, "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: 0.00. 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": "JDSA010", "label": "Fermeture du col de la vessie pour cystostomie cutan\u00e9e continente", "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": 0.54, "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: 0.00. 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": "HJFA014", "label": "Ex\u00e9r\u00e8se de moignon rectal r\u00e9siduel, par abord p\u00e9rin\u00e9al", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC002", "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": 0.54, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"section du canal cystique apr\u00e8s contr\u00f4le du moignon cystique restant par deux clips (HEMOLOCK 5)\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docte\" (document: 15_23096332_DOC002). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "DEGF002", "label": "Ablation de plusieurs sondes d\u00e9finitives intracavitaires de stimulation cardiaque sans utilisation de dispositif sp\u00e9cifique, par voie veineuse transcutan\u00e9e", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC002", "span": {"start": 523, "end": 647}, "text": "    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n    Anesth", "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'intern..."}], "confidence": 0.54, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"ablation de tous les trocarts sous contr\u00f4le de la vue\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"    Diagnostic : chol\u00e9cystite \n    Compte rendu op\u00e9ratoire du 18/05/2023 : \n    Op\u00e9rateur : Docteur R. DIDAILLER \n    Anesth\" (document: 15_23096332_DOC002). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "YYYY755", "label": "Suppl\u00e9ment pour avulsion de 4 troisi\u00e8mes molaires retenues ou \u00e0 l'\u00e9tat de germe r\u00e9alis\u00e9e en cabinet sous anesth\u00e9sie locale", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 0, "end": 74}, "text": "N\u00b0 Finess CENTRE HOSPITALIER COTE BASQUE\n*640000162* \u2709 13, Avenue de l'Int", "context": "N\u00b0 Finess CENTRE HOSPITALIER COTE BASQUE\n*640000162* \u2709 13, Avenue de l'Interne J. LOEB BP 8, 64109 BAYONNE CEDEX\n640000162\nC..."}], "confidence": 0.54, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"Admission en urgence en chirurgie visc\u00e9rale\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"N\u00b0 Finess CENTRE HOSPITALIER COTE BASQUE\n*640000162* \u2709 13, Avenue de l'Int\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "PANL001", "label": "Irradiation interne d'une l\u00e9sion osseuse par injection intraveineuse d'agent pharmacologique radio-isotopique", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 2241, "end": 2305}, "text": "Episode N.: 23096332 ( CHIRURGIE VISCERALE - CHIRURGIE VISC.A2 )", "context": "...IAN - Date de naissance: 22/09/1949   (23011489 )\nEpisode N.: 23096332 ( CHIRURGIE VISCERALE - CHIRURGIE VISC.A2 ) - Taille: 173 cm - Poids: 90 kg - IMC: 30.071\nLe ..."}], "confidence": 0.54, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"chirurgie visc\u00e9rale\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"Episode N.: 23096332 ( CHIRURGIE VISCERALE - CHIRURGIE VISC.A2 )\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "EKLA001", "label": "Pose d'une d\u00e9rivation art\u00e9rioveineuse au membre sup\u00e9rieur, par abord direct", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 10142, "end": 10150}, "text": "KTO pos\u00e9", "context": "...attendant place ds un boxBS pr\u00e9lev\u00e9H\u00e9mocs envoy\u00e9esKTO pos\u00e9"}], "confidence": 0.9400000000000001, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"Pose de cath\u00e9ter veineux (KTO)\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 1.00. Preuve textuelle: \"KTO pos\u00e9\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "UNKNOWN", "label": "## CHAPITRE 5.0: Majoration pour la mise en \u0153uvre perop\u00e9ratoire et le suivi d\u2019une analg\u00e9sie postop\u00e9r", "type": "ccam", "evidence": [{"document_id": "15_23096332_DOC004", "span": {"start": 9414, "end": 9433}, "text": "mob 1 er lever fait", "context": "...tion cy ce soir\n- transit g-s-\n- \u00e9limination u+\n- mob 1 er lever fait\nNote IDE Laure BIDART 18/05/2023\n12:44 Bloc: ce j..."}], "confidence": 0.54, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"Premier lever post-op\u00e9ratoire\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. Preuve textuelle: \"mob 1 er lever fait\" (document: 15_23096332_DOC004). Acte m\u00e9dical r\u00e9alis\u00e9 pendant le s\u00e9jour.", "referentiel_version": "2025"}, {"code": "ZZMK019", "label": "Reprise de pr\u00e9paration \u00e0 une irradiation externe sans dosim\u00e9trie, avec simulation sous l'appareil de traitement", "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": 0.54, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"Pr\u00e9paration pr\u00e9-op\u00e9ratoire\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.00. 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": "BDEA002", "label": "\u00c9pik\u00e9ratophakie", "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": 0.6130830430984497, "reasoning": "Code propos\u00e9 comme Acte m\u00e9dical. Bas\u00e9 sur le fait clinique: \"Retour de bloc op\u00e9ratoire\" (type: acte, certitude: affirm\u00e9, temporalit\u00e9: actuel). Score de similarit\u00e9 RAG: 0.18. 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": "GLLP007", "label": "Oxyg\u00e9noth\u00e9rapie hyperbare avec inhalation d\u2019oxyg\u00e8ne pur d'une dur\u00e9e minimale de 60 minutes \u00e0 une pression de 200 \u00e0 280 kilopascals [kPa] chez un patient en ventilation spontan\u00e9e, pour affection en phase aig\u00fce", "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": 0.54, "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: 0.00. 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": "EQRP001", "label": "S\u00e9ance de r\u00e9entra\u00eenement cardiaque et/ou vasculaire progressif \u00e0 l'effort sur machine", "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": 0.54, "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: 0.00. 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": "EJSF032", "label": "Occlusion de la grande veine saph\u00e8ne au-dessus du tiers moyen de la jambe par radiofr\u00e9quence, par voie veineuse transcutan\u00e9e avec guidage \u00e9chographique et phl\u00e9bectomie homolat\u00e9rale, et/ou ligature de veine perforante de la grande veine saph\u00e8ne homolat\u00e9rale", "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": 0.54, "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: 0.00. 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). 234 faits cliniques ont \u00e9t\u00e9 extraits et analys\u00e9s. Diagnostic Principal (DP): T09.1 - Plaie ouverte du tronc, niveau non pr\u00e9cis\u00e9 (confiance: 0.54). Diagnostic Reli\u00e9 (DR): K80 - Chol\u00e9lithiase (confiance: 0.64). 21 Diagnostic(s) Associ\u00e9(s) Significatif(s) (DAS) propos\u00e9(s). 27 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 HBLD245 propos\u00e9 sans preuve explicite d'acte. Fait source de type: traitement", "affected_codes": ["HBLD245"], "severity": "bloquant"}, {"error_type": "act_without_evidence", "message": "Acte CCAM GLLP007 propos\u00e9 sans preuve explicite d'acte. Fait source de type: examen", "affected_codes": ["GLLP007"], "severity": "bloquant"}, {"error_type": "dp_das_inversion", "message": "Possible inversion DP/DAS: DAS X46 (confiance: 0.94) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)", "affected_codes": ["T09.1", "X46"], "severity": "a_revoir"}, {"error_type": "dp_das_inversion", "message": "Possible inversion DP/DAS: DAS V39.6 (confiance: 0.78) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)", "affected_codes": ["T09.1", "V39.6"], "severity": "a_revoir"}, {"error_type": "dp_das_inversion", "message": "Possible inversion DP/DAS: DAS O08.1 (confiance: 0.68) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)", "affected_codes": ["T09.1", "O08.1"], "severity": "a_revoir"}, {"error_type": "dp_das_inversion", "message": "Possible inversion DP/DAS: DAS E78 (confiance: 0.94) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)", "affected_codes": ["T09.1", "E78"], "severity": "a_revoir"}, {"error_type": "dp_das_inversion", "message": "Possible inversion DP/DAS: DAS D71 (confiance: 0.75) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)", "affected_codes": ["T09.1", "D71"], "severity": "a_revoir"}], "contradictions": [], "alternatives": [{"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": "Alternative au DP T09.1: 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: 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 DAS car il a eu un impact significatif sur la prise en charge.", "referentiel_version": "2026"}], "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 50 code(s): DP=T09.1, DR=K80, 21 DAS, 27 CCAM. 7 erreur(s) sensible(s) DIM d\u00e9tect\u00e9e(s):   - [BLOQUANT] act_without_evidence: Acte CCAM HBLD245 propos\u00e9 sans preuve explicite d'acte. Fait source de type: traitement   - [BLOQUANT] act_without_evidence: Acte CCAM GLLP007 propos\u00e9 sans preuve explicite d'acte. Fait source de type: examen   - [A_REVOIR] dp_das_inversion: Possible inversion DP/DAS: DAS X46 (confiance: 0.94) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)   - [A_REVOIR] dp_das_inversion: Possible inversion DP/DAS: DAS V39.6 (confiance: 0.78) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)   - [A_REVOIR] dp_das_inversion: Possible inversion DP/DAS: DAS O08.1 (confiance: 0.68) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)   - [A_REVOIR] dp_das_inversion: Possible inversion DP/DAS: DAS E78 (confiance: 0.94) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54)   - [A_REVOIR] dp_das_inversion: Possible inversion DP/DAS: DAS D71 (confiance: 0.75) a une confiance sup\u00e9rieure au DP T09.1 (confiance: 0.54) Aucune contradiction d\u00e9tect\u00e9e. 1 alternative(s) sugg\u00e9r\u00e9e(s):   - X46 (dp): Intoxication accidentelle par des solvants organiques et des hydrocarbures halog\u00e9n\u00e9s et leurs \u00e9manations (confiance: 0.94) 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_34324482935eea5c
timestamp: 2026-02-12 00:47:10.917459
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 00:47:10.922414
data:
  {"fact_count": 252, "facts_by_type": {"acte": 50, "diagnostic": 42, "examen": 64, "traitement": 86, "complication": 10}, "facts_by_certainty": {"affirm\u00e9": 246, "suspect\u00e9": 3, "ni\u00e9": 3}, "facts": [{"fact_id": "4e1892a3-7857-43cd-a0c9-6b614d25e82c", "type": "acte", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 0.9, "evidence_document_id": "15_23096332_DOC001"}, {"fact_id": "faf44725-0f13-40a3-939d-4fb63bcd64b5", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 0.9, "evidence_document_id": "15_23096332_DOC001"}, {"fact_id": "04107568-80d3-46b7-bcc9-58a11d82825f", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 0.9, "evidence_document_id": "15_23096332_DOC001"}, {"fact_id": "e928a810-b07c-4908-85a1-06b256ad0209", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 0.9, "evidence_document_id": "15_23096332_DOC001"}, {"fact_id": "d5059875-f2e7-409f-aa0c-3ef145608552", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 0.9, "evidence_document_id": "15_23096332_DOC001"}, {"fact_id": "4efa5bab-136c-437e-9f55-d29ad3a697fe", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 0.9, "evidence_document_id": "15_23096332_DOC001"}, {"fact_id": "630107d6-b284-44cf-8780-9ae63770f377", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 0.9, "evidence_document_id": "15_23096332_DOC001"}, {"fact_id": "16bb5060-db46-43b5-aad9-855e3aad09c9", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 0.9, "evidence_document_id": "15_23096332_DOC001"}, {"fact_id": "0707b82b-0a52-4fc7-a49f-94a8c1e36e89", "type": "diagnostic", "qualifier_certainty": "affirm\u00e9", "temporality": "actuel", "confidence": 0.9, 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