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t2a/output/structured/149_23089771/CRO_23089771_cim10.json
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{
"source_file": "CRO 23089771.pdf",
"document_type": "crh",
"sejour": {
"sexe": "M"
},
"diagnostics_associes": [
{
"texte": "Décollement de la",
"cim10_suggestion": "H33.2",
"cim10_confidence": "high",
"sources_rag": [],
"preuves_cliniques": [],
"niveau_severite": "non_evalue",
"niveau_cma": 1,
"source": "edsnlp",
"source_page": 1,
"source_excerpt": "...ritoine au niveau de la gouttière pariéto-colique et décollement colique dans le plan du fascia d\n- Décollement de la queue du pancréas et libération splénique jusquà permettre une bascule complète du blo\n- Dissectio..."
},
{
"texte": "C omprend décollement de la (de la) : • conjonctive",
"cim10_suggestion": "H16.0",
"cim10_confidence": "high",
"justification": "Correspondance directe avec le libellé CIM-10 : H16.0 C omprend décollement de la (de la) : • conjonctive.",
"sources_rag": [],
"preuves_cliniques": [],
"est_cma": true,
"niveau_severite": "non_evalue",
"niveau_cma": 2,
"source": "llm_das"
},
{
"texte": "C omprend décollement de la (de la) : • cornée",
"cim10_suggestion": "H16.1",
"cim10_confidence": "high",
"justification": "Correspondance directe avec le libellé CIM-10 : H16.1 C omprend décollement de la (de la) : • cornée.",
"sources_rag": [],
"preuves_cliniques": [],
"est_cma": true,
"niveau_severite": "non_evalue",
"niveau_cma": 2,
"source": "llm_das"
},
{
"texte": "C omprend décollement de la (de la) : • membrane de Descemet",
"cim10_suggestion": "H16.2",
"cim10_confidence": "high",
"justification": "Correspondance directe avec le libellé CIM-10 : H16.2 C omprend décollement de la (de la) : • membrane de Descemet.",
"sources_rag": [],
"preuves_cliniques": [],
"est_cma": true,
"niveau_severite": "non_evalue",
"niveau_cma": 2,
"source": "llm_das"
}
],
"actes_ccam": [],
"antecedents": [],
"traitements_sortie": [],
"biologie_cle": [],
"imagerie": [],
"complications": [],
"alertes_codage": [
"3 CMA probables détectées — impact potentiel sur le niveau de sévérité GHM",
"CMA niveau 2 : 'C omprend décollement de la (de la) : • conjonctive' (H16.0) — sévérité non_evalue",
"CMA niveau 2 : 'C omprend décollement de la (de la) : • cornée' (H16.1) — sévérité non_evalue",
"CMA niveau 2 : 'C omprend décollement de la (de la) : • membrane de Descemet' (H16.2) — sévérité non_evalue",
"QC: DAS H16.0 (C omprend décollement de la (de la) : • conjonctive) à reconsidérer — Le code H16.0 décrit un décollement de la conjonctive, ce qui n'est pas le diagnostic principal. Il est donc supprimé.",
"QC: DAS H16.1 (C omprend décollement de la (de la) : • cornée) à reconsidérer — Le code H16.1 décrit un décollement de la cornée, ce qui n'est pas le diagnostic principal. Il est donc supprimé.",
"QC: DAS H16.2 (C omprend décollement de la (de la) : • membrane de Descemet) à reconsidérer — Le code H16.2 décrit un décollement de la membrane de Descemet, ce qui n'est pas le diagnostic principal. Il est donc supprimé.",
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"source_files": [],
"ghm_estimation": {
"type_ghm": "M",
"severite": 2,
"cma_count": 3,
"cms_count": 0,
"alertes": [
"DP absent — CMD non déterminable"
]
},
"controles_cpam": [],
"processing_time_s": 26.59
}