t2a_v2/output/structured/10_23079252/CRO_23079252_cim10.json

{
  "source_file": "CRO 23079252.pdf",
  "document_type": "crh",
  "sejour": {
    "sexe": "M"
  },
  "diagnostic_principal": {
    "texte": "Cholécystite aiguë",
    "cim10_suggestion": "K81.0",
    "cim10_confidence": "high",
    "cim10_final": "K81.0",
    "cim10_decision": {
      "action": "PROMOTE_DP",
      "final_code": "K81.0",
      "reason": "DAS promu en DP (score (2, 3, 4))",
      "needs_info": [],
      "applied_rules": [
        "RULE-DAS-TO-DP"
      ]
    },
    "sources_rag": [],
    "preuves_cliniques": [],
    "source": "regex",
    "source_page": 1,
    "source_excerpt": "...4600 ANGLET\nMonsieur BENOIT RAMEIX\nNé le 16/02/1975\nCHOLECYSTECTOMIE SOUS COELIOSCOPIE\nIndication :\nCholécystite aiguë\nCompte rendu opératoire du 22.04.2023 :\nOpérateur : Docteur R. GONTIER\nAnesthésiste(s) Docteur L. K..."
  },
  "dp_selection": {
    "chosen_index": 0,
    "chosen_term": "Cholécystite aiguë",
    "chosen_code": "K81.0",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 3.0 — source: regex (section forte)"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Cholécystite aiguë",
        "code": "K81.0",
        "source": "regex",
        "is_comorbidity_like": false,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 3.0,
        "score_details": {
          "section": 3,
          "confidence": 0
        }
      }
    ],
    "debug_scores": {
      "top1": 3.0
    }
  },
  "dp_crh_only": {
    "chosen_index": 0,
    "chosen_term": "Cholécystite aiguë",
    "chosen_code": "K81.0",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 3.0 — source: regex (section forte)"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Cholécystite aiguë",
        "code": "K81.0",
        "source": "regex",
        "is_comorbidity_like": false,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 3.0,
        "score_details": {
          "section": 3,
          "confidence": 0
        }
      }
    ],
    "debug_scores": {
      "top1": 3.0
    }
  },
  "dp_final": {
    "chosen_index": 0,
    "chosen_term": "Cholécystite aiguë",
    "chosen_code": "K81.0",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 3.0 — source: regex (section forte)"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Cholécystite aiguë",
        "code": "K81.0",
        "source": "regex",
        "is_comorbidity_like": false,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 3.0,
        "score_details": {
          "section": 3,
          "confidence": 0
        }
      }
    ],
    "debug_scores": {
      "top1": 3.0
    }
  },
  "quality_flags": {
    "rag_status": "error",
    "crh_only_mode": true
  },
  "diagnostics_associes": [],
  "actes_ccam": [
    {
      "texte": "Cholécystectomie",
      "code_ccam_suggestion": "HMFC004",
      "sources_rag": [],
      "validite": "valide",
      "alertes": [],
      "source_page": 1,
      "source_excerpt": "...ouver l’artèr\ncanal cystique.\nSection entre clips du canal cystique et de l’artère.\nPoursuite de la cholécystectomie rétrograde.\nElectrocoagulation du lit vésiculaire\nOn positionne la vésicule dans un sac d’extractio..."
    }
  ],
  "antecedents": [],
  "traitements_sortie": [],
  "biologie_cle": [],
  "biologie_discarded": [],
  "imagerie": [],
  "complications": [],
  "alertes_codage": [
    "QUALITE DEGRADEE : erreur RAG — codage sans référentiels",
    "CMA niveau 3 : 'Cholécystite aiguë' (K81.0) — sévérité severe, marqueurs : aigue",
    "QC: DAS K81.0 (Cholécystite aiguë) à reconsidérer — ABSENCE TOTALE DE PREUVE CLINIQUE. Le codage indique explicitement 'Preuves: aucune'. Un diagnostic de cholécystite aiguë ne peut être codé sans justification documentée (clinique, biologique, imagerie). Cela constitue un codage non fondé.",
    "QC: ⚠️ ANOMALIE CRITIQUE : Codage sans justification médicale",
    "QC: ⚠️ RISQUE DE FACTURATION INJUSTIFIÉE : K81.0 est un diagnostic majeur pouvant impacter le GHM",
    "QC: ⚠️ NON-CONFORMITÉ PMSI : Tout diagnostic doit être étayé par des éléments du dossier (clinique, paraclinique, imagerie)",
    "QC: ⚠️ DOSSIER INCOMPLET : Aucune information clinique fournie pour valider ce codage",
    "QC: RECOMMANDATION : Soit supprimer ce code, soit fournir les preuves documentées (symptômes, résultats biologiques, échographie, etc.)",
    "RULE-DAS-TO-DP: DP absent → DAS K81.0 (Cholécystite aiguë) promu en DP",
    "DECISIONS[PDF]: 1 ligne(s)",
    "DECISION: diagnostic_principal K81.0 promu en DP (RULE-DAS-TO-DP)"
  ],
  "source_files": [],
  "ghm_estimation": {
    "cmd": "07",
    "cmd_libelle": "Affections hépatobiliaires et pancréatiques",
    "type_ghm": "C",
    "severite": 1,
    "ghm_approx": "07C??1",
    "cma_count": 0,
    "cms_count": 0,
    "alertes": []
  },
  "controles_cpam": [],
  "veto_report": {
    "verdict": "PASS",
    "score_contestabilite": 100,
    "issues": []
  },
  "completude": {
    "checks": [
      {
        "code": "HMFC004",
        "libelle": "Acte chirurgical nécessitant un CRO",
        "type_diag": "Acte",
        "items": [
          {
            "categorie": "document",
            "element": "CRO",
            "statut": "absent",
            "importance": "obligatoire",
            "impact_cpam": "Compte-rendu opératoire obligatoire pour tout acte chirurgical"
          }
        ],
        "score": 30,
        "verdict": "indefendable",
        "resume": "0/1 obligatoires"
      }
    ],
    "score_global": 30,
    "verdict_global": "indefendable",
    "documents_presents": [
      "crh"
    ],
    "documents_manquants": [
      "CRO"
    ]
  },
  "processing_time_s": 6.37,
  "metrics": {
    "das_total": 0,
    "das_active": 0,
    "das_excluded": 0,
    "das_removed": 0,
    "das_ruled_out": 0,
    "das_no_code": 0,
    "actes_total": 1,
    "actes_with_code": 1,
    "dp_has_code": true
  },
  "rules_runtime": {
    "router_version": 1,
    "mode": "strict",
    "enabled_packs": [
      "decisions_core",
      "vetos_core"
    ],
    "always_on_rules": [],
    "triggers_fired": []
  }
}