{
  "source_file": "CRH 23096269.pdf",
  "document_type": "crh",
  "sejour": {
    "sexe": "F",
    "age": 65,
    "date_entree": "30/05/2023",
    "date_sortie": "02/06/2023",
    "duree_sejour": 3
  },
  "diagnostic_principal": {
    "texte": "Diabète de type 2",
    "cim10_suggestion": "E11.9",
    "cim10_confidence": "high",
    "cim10_final": "E11.9",
    "sources_rag": [],
    "preuves_cliniques": [],
    "est_cma": true,
    "niveau_severite": "non_evalue",
    "niveau_cma": 2,
    "source": "nuke3",
    "source_page": 2,
    "source_excerpt": "...E (avant chirurgie genou) à la clinique de St Jean de Luz\nSecrétariat :\n05.59.44.37.33 Conclusion : Diabète de type 2 avec HbA1c en amélioration à 7.8% mais problématique d'hypoglycémies à répétition.\nENDOCRINOLOGIE S..."
  },
  "dp_selection": {
    "chosen_index": 1,
    "chosen_term": "Diabète de type 2",
    "chosen_code": "E11.9",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 4.0 — source: regex (section forte)",
      "Motif hospitalisation: «Dr Elisa MAURY\nDr Laurence RITZ-QUILLACQ\nD D r r M M a a r th io ie n u G A S U C Z H I WIND - MT Dr Foucaud\nSecrétariat :\n05.59.44.37.42 Motif d’hospitalisation\nMAL. INFECTIEUSES Tentative de sevrage en rapides dans le cadre d'un diabète d»",
      "Delta +3.0 vs Trouble anxio-dépressif (F41.9)"
    ],
    "reason": "Écart score 3.0 >= seuil 3.0",
    "candidates": [
      {
        "index": 1,
        "term": "Diabète de type 2",
        "code": "E11.9",
        "source": "regex",
        "is_comorbidity_like": true,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 4.0,
        "score_details": {
          "section": 3,
          "confidence": 0,
          "motif_align": 2,
          "diag_section_bonus": 2,
          "comorbidity_malus": -3
        }
      },
      {
        "index": 3,
        "term": "Trouble anxio-dépressif",
        "code": "F41.9",
        "source": "llm_das",
        "is_comorbidity_like": false,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 1,
        "num_occurrences": 1,
        "score": 1.0,
        "score_details": {
          "section": 1,
          "confidence": 0
        }
      },
      {
        "index": 0,
        "term": "Hypertension artérielle",
        "code": "I10",
        "source": "regex",
        "is_comorbidity_like": true,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 0.0,
        "score_details": {
          "section": 3,
          "confidence": 0,
          "comorbidity_malus": -3
        }
      },
      {
        "index": 2,
        "term": "Obésité (IMC 41.49)",
        "code": "E66.0",
        "source": "regex",
        "is_comorbidity_like": true,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 0.0,
        "score_details": {
          "section": 3,
          "confidence": 0,
          "comorbidity_malus": -3
        }
      }
    ],
    "debug_scores": {
      "top1": 4.0,
      "top2": 1.0,
      "delta": 3.0
    }
  },
  "dp_crh_only": {
    "chosen_index": 1,
    "chosen_term": "Diabète de type 2",
    "chosen_code": "E11.9",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 4.0 — source: regex (section forte)",
      "Motif hospitalisation: «Dr Elisa MAURY\nDr Laurence RITZ-QUILLACQ\nD D r r M M a a r th io ie n u G A S U C Z H I WIND - MT Dr Foucaud\nSecrétariat :\n05.59.44.37.42 Motif d’hospitalisation\nMAL. INFECTIEUSES Tentative de sevrage en rapides dans le cadre d'un diabète d»",
      "Delta +3.0 vs Trouble anxio-dépressif (F41.9)"
    ],
    "reason": "Écart score 3.0 >= seuil 3.0",
    "candidates": [
      {
        "index": 1,
        "term": "Diabète de type 2",
        "code": "E11.9",
        "source": "regex",
        "is_comorbidity_like": true,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 4.0,
        "score_details": {
          "section": 3,
          "confidence": 0,
          "motif_align": 2,
          "diag_section_bonus": 2,
          "comorbidity_malus": -3
        }
      },
      {
        "index": 3,
        "term": "Trouble anxio-dépressif",
        "code": "F41.9",
        "source": "llm_das",
        "is_comorbidity_like": false,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 1,
        "num_occurrences": 1,
        "score": 1.0,
        "score_details": {
          "section": 1,
          "confidence": 0
        }
      },
      {
        "index": 0,
        "term": "Hypertension artérielle",
        "code": "I10",
        "source": "regex",
        "is_comorbidity_like": true,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 0.0,
        "score_details": {
          "section": 3,
          "confidence": 0,
          "comorbidity_malus": -3
        }
      },
      {
        "index": 2,
        "term": "Obésité (IMC 41.49)",
        "code": "E66.0",
        "source": "regex",
        "is_comorbidity_like": true,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 0.0,
        "score_details": {
          "section": 3,
          "confidence": 0,
          "comorbidity_malus": -3
        }
      }
    ],
    "debug_scores": {
      "top1": 4.0,
      "top2": 1.0,
      "delta": 3.0
    }
  },
  "dp_final": {
    "chosen_index": 1,
    "chosen_term": "Diabète de type 2",
    "chosen_code": "E11.9",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 4.0 — source: regex (section forte)",
      "Motif hospitalisation: «Dr Elisa MAURY\nDr Laurence RITZ-QUILLACQ\nD D r r M M a a r th io ie n u G A S U C Z H I WIND - MT Dr Foucaud\nSecrétariat :\n05.59.44.37.42 Motif d’hospitalisation\nMAL. INFECTIEUSES Tentative de sevrage en rapides dans le cadre d'un diabète d»",
      "Delta +3.0 vs Trouble anxio-dépressif (F41.9)"
    ],
    "reason": "Écart score 3.0 >= seuil 3.0",
    "candidates": [
      {
        "index": 1,
        "term": "Diabète de type 2",
        "code": "E11.9",
        "source": "regex",
        "is_comorbidity_like": true,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 4.0,
        "score_details": {
          "section": 3,
          "confidence": 0,
          "motif_align": 2,
          "diag_section_bonus": 2,
          "comorbidity_malus": -3
        }
      },
      {
        "index": 3,
        "term": "Trouble anxio-dépressif",
        "code": "F41.9",
        "source": "llm_das",
        "is_comorbidity_like": false,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 1,
        "num_occurrences": 1,
        "score": 1.0,
        "score_details": {
          "section": 1,
          "confidence": 0
        }
      },
      {
        "index": 0,
        "term": "Hypertension artérielle",
        "code": "I10",
        "source": "regex",
        "is_comorbidity_like": true,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 0.0,
        "score_details": {
          "section": 3,
          "confidence": 0,
          "comorbidity_malus": -3
        }
      },
      {
        "index": 2,
        "term": "Obésité (IMC 41.49)",
        "code": "E66.0",
        "source": "regex",
        "is_comorbidity_like": true,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 0.0,
        "score_details": {
          "section": 3,
          "confidence": 0,
          "comorbidity_malus": -3
        }
      }
    ],
    "debug_scores": {
      "top1": 4.0,
      "top2": 1.0,
      "delta": 3.0
    }
  },
  "quality_flags": {
    "rag_status": "error",
    "crh_only_mode": true
  },
  "diagnostics_associes": [
    {
      "texte": "Hypertension artérielle",
      "cim10_suggestion": "I10",
      "cim10_confidence": "high",
      "cim10_final": "I10",
      "sources_rag": [],
      "preuves_cliniques": [],
      "niveau_severite": "non_evalue",
      "niveau_cma": 1,
      "source": "regex"
    },
    {
      "texte": "Obésité (IMC 41.49)",
      "cim10_suggestion": "E66.0",
      "cim10_confidence": "high",
      "cim10_final": "E66.0",
      "sources_rag": [],
      "preuves_cliniques": [],
      "niveau_severite": "non_evalue",
      "niveau_cma": 1,
      "source": "regex"
    },
    {
      "texte": "Trouble anxio-dépressif",
      "cim10_suggestion": "F41.9",
      "cim10_confidence": "low",
      "cim10_final": "F41.9",
      "justification": "Mention explicite dans le texte : 'Proposition de suivi psychologique avec coordonnées remises pour possible sd anxio dépressif'. Diagnostic identifié pendant le séjour ayant mobilisé des ressources (orientation vers suivi psychologique).",
      "sources_rag": [],
      "preuves_cliniques": [],
      "niveau_severite": "non_evalue",
      "niveau_cma": 1,
      "source": "llm_das"
    }
  ],
  "actes_ccam": [],
  "antecedents": [
    {
      "texte": "/Maladie en cours",
      "source_page": 1,
      "source_excerpt": "...e en rapides dans le cadre d'un diabète de type 2\nDr Marc Olivier VAREIL\nChef de Service Antécédents/Maladie en cours\nDr Sophie FARBOS\nDr Heidi WILLE Diabète\nDr Laure ALLEMAN HTA\nDr Margaux BOUET\nSecrétariat :\nTraitem..."
    },
    {
      "texte": "Traitement à l’entrée",
      "source_page": 1,
      "source_excerpt": "...n cours\nDr Sophie FARBOS\nDr Heidi WILLE Diabète\nDr Laure ALLEMAN HTA\nDr Margaux BOUET\nSecrétariat :\nTraitement à l’entrée\n05.59.44.37.32\nmetformine 850x2 Novorapid 28-28-36 Toujeo 70U le soir Vesicare questran Hyzaar 100/..."
    },
    {
      "texte": "metformine 850x2 Novorapid 28-28-36 Toujeo 70U le soir Vesicare questran Hyzaar 100/25 Pravastatine 20",
      "source_page": 1,
      "source_excerpt": "...LE Diabète\nDr Laure ALLEMAN HTA\nDr Margaux BOUET\nSecrétariat :\nTraitement à l’entrée\n05.59.44.37.32\nmetformine 850x2 Novorapid 28-28-36 Toujeo 70U le soir Vesicare questran Hyzaar 100/25 Pravastatine 20\nNEPHROLOGIE\nDr Adeline LACRAZ\nMode de vie/Habitus\nChef de Service\nDr Pauline D'HALLUIN habite avec..."
    }
  ],
  "traitements_sortie": [],
  "biologie_cle": [
    {
      "test": "GGT",
      "valeur": "58",
      "valeur_num": 58.0,
      "anomalie": false,
      "quality": "ok",
      "source_page": 1,
      "source_excerpt": "...ferme\nMetformine 850 bien tolérée\nBiologie à l'entrée :\nHbA1c 7.8%\nCRP nég\ntransaminases normales, GGT 58 U/L\nLDL 0.61 g/l, HDL 0.42 g/L, TG 1.45 g/L\nHb 12.6 g/dL, ferritine 44 ug/l\nTSH normale\nEvolutio..."
    },
    {
      "test": "Hémoglobine",
      "valeur": "12.6",
      "valeur_num": 12.6,
      "anomalie": false,
      "quality": "ok",
      "source_page": 2,
      "source_excerpt": "...e le service avec:\nChef de Service\nDr Sophie FARBOS - Laboratoire :\nDr Heidi WILLE\nDr Laure ALLEMAN Hémoglobine glycosylée HbA1C ( dosage )\nDr Margaux BOUET - Matériel :\nSecrétariat : Bandelettes Cétonémie 1xjou..."
    },
    {
      "test": "HbA1c",
      "valeur": "13",
      "valeur_num": 13.0,
      "anomalie": true,
      "quality": "ok",
      "source_page": 1,
      "source_excerpt": "...nue du service depuis 2007 initialement Dr Ritz puis Dr GSCHWIND puis Dr Maury\nRHUMATOLOGIE En 2018 HbA1c = 13% poids 82Kg sous ADO + Xultophy : hospitalisation de semaine pour rajout d'insuline rapide le..."
    },
    {
      "test": "HbA1c",
      "valeur": "7.8",
      "valeur_num": 7.8,
      "anomalie": true,
      "quality": "ok",
      "source_page": 1,
      "source_excerpt": "...nue du service depuis 2007 initialement Dr Ritz puis Dr GSCHWIND puis Dr Maury\nRHUMATOLOGIE En 2018 HbA1c = 13% poids 82Kg sous ADO + Xultophy : hospitalisation de semaine pour rajout d'insuline rapide le..."
    }
  ],
  "biologie_discarded": [],
  "imagerie": [],
  "complications": [],
  "alertes_codage": [
    "QUALITE DEGRADEE : erreur RAG — codage sans référentiels",
    "CMA niveau 2 : 'Diabète de type 2' (E11.9) — sévérité non_evalue",
    "QC: ⚠️ ALERTE CRITIQUE : F41.9 codé sur suspicion uniquement - non conforme aux règles de codage PMSI (diagnostic établi requis)",
    "QC: ⚠️ Deux valeurs HbA1c contradictoires (13% vs 7.8%) - clarifier la chronologie et la validité",
    "QC: ⚠️ Absence totale de justifications documentées pour E11.9, I10, E66.0 dans le dossier fourni - vérifier la complétude du dossier clinique",
    "QC: ⚠️ Absence de valeurs tensionnelles pour justifier I10 - recommander documentation",
    "QC: ⚠️ Absence de diagnostic principal clairement énoncé - le DP (E11.9) semble par défaut plutôt que justifié par le motif d'admission",
    "QC: ℹ️ Vérifier le motif d'admission réel (3 jours) - aucun événement aigu documenté",
    "VETOS[PDF]: NEED_INFO (score=55)",
    "VETO-02 [MEDIUM] diagnostics_associes[0]: DAS I10 sans preuve exploitable",
    "VETO-02 [MEDIUM] diagnostics_associes[1]: DAS E66.0 sans preuve exploitable",
    "VETO-02 [MEDIUM] diagnostics_associes[2]: DAS F41.9 sans preuve exploitable"
  ],
  "source_files": [],
  "ghm_estimation": {
    "cmd": "10",
    "cmd_libelle": "Maladies endocriniennes",
    "type_ghm": "M",
    "severite": 1,
    "ghm_approx": "10M??1",
    "cma_count": 0,
    "cms_count": 0,
    "alertes": []
  },
  "controles_cpam": [],
  "veto_report": {
    "verdict": "NEED_INFO",
    "score_contestabilite": 55,
    "issues": [
      {
        "veto": "VETO-02",
        "severity": "MEDIUM",
        "where": "diagnostics_associes[0]",
        "message": "DAS I10 sans preuve exploitable",
        "citation": "Principe de preuve : tout diagnostic/acte doit être étayé par une trace dans le dossier médical (Guide Méthodologique MCO)"
      },
      {
        "veto": "VETO-02",
        "severity": "MEDIUM",
        "where": "diagnostics_associes[1]",
        "message": "DAS E66.0 sans preuve exploitable",
        "citation": "Principe de preuve : tout diagnostic/acte doit être étayé par une trace dans le dossier médical (Guide Méthodologique MCO)"
      },
      {
        "veto": "VETO-02",
        "severity": "MEDIUM",
        "where": "diagnostics_associes[2]",
        "message": "DAS F41.9 sans preuve exploitable",
        "citation": "Principe de preuve : tout diagnostic/acte doit être étayé par une trace dans le dossier médical (Guide Méthodologique MCO)"
      }
    ]
  },
  "completude": {
    "checks": [
      {
        "code": "E11.9",
        "libelle": "Diabète de type 2",
        "type_diag": "DP",
        "items": [
          {
            "categorie": "biologie",
            "element": "HbA1c",
            "statut": "present",
            "valeur": "12.6",
            "importance": "recommande",
            "impact_cpam": "HbA1c attendue pour documenter l'équilibre glycémique"
          },
          {
            "categorie": "biologie",
            "element": "Glycémie",
            "statut": "absent",
            "importance": "recommande",
            "impact_cpam": "Glycémie de base pour confirmer le diagnostic"
          }
        ],
        "score": 85,
        "verdict": "defendable",
        "resume": "1/2 recommandés"
      },
      {
        "code": "E66.0",
        "libelle": "Obésité (IMC 41.49)",
        "type_diag": "DAS",
        "items": [
          {
            "categorie": "clinique",
            "element": "IMC",
            "statut": "absent",
            "importance": "obligatoire",
            "impact_cpam": "IMC ≥ 30 indispensable pour coder une obésité"
          },
          {
            "categorie": "clinique",
            "element": "Poids",
            "statut": "absent",
            "importance": "obligatoire",
            "impact_cpam": "Poids nécessaire pour calculer l'IMC"
          }
        ],
        "score": 30,
        "verdict": "indefendable",
        "resume": "0/2 obligatoires"
      }
    ],
    "score_global": 57,
    "verdict_global": "indefendable",
    "documents_presents": [
      "crh"
    ],
    "documents_manquants": []
  },
  "processing_time_s": 19.14,
  "metrics": {
    "das_total": 3,
    "das_active": 3,
    "das_excluded": 0,
    "das_removed": 0,
    "das_ruled_out": 0,
    "das_no_code": 0,
    "actes_total": 0,
    "actes_with_code": 0,
    "dp_has_code": true
  },
  "rules_runtime": {
    "router_version": 1,
    "mode": "strict",
    "enabled_packs": [
      "decisions_core",
      "vetos_core"
    ],
    "always_on_rules": [],
    "triggers_fired": []
  }
}