13fe9fa666
Résultats de re-traitement pipeline v2 sur 261 dossiers. Co-Authored-By: Claude Opus 4.6 <noreply@anthropic.com>
291 lines
9.0 KiB
JSON
291 lines
9.0 KiB
JSON
{
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"source_file": "CRH 23071970.pdf",
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"document_type": "crh",
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"sejour": {
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"sexe": "M",
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"age": 23,
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"date_entree": "11/04/2023",
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"date_sortie": "17/04/2023",
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"duree_sejour": 6
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},
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"diagnostic_principal": {
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"texte": "Pneumopathie",
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"cim10_suggestion": "J18.9",
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"cim10_confidence": "low",
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"cim10_final": "J18.9",
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"cim10_decision": {
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"action": "PROMOTE_DP",
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"final_code": "J18.9",
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"reason": "DAS promu en DP (score (2, 1, 4))",
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"needs_info": [],
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"applied_rules": [
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"RULE-DAS-TO-DP"
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]
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},
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"sources_rag": [],
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"preuves_cliniques": [],
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"source": "regex",
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"source_page": 1,
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"source_excerpt": "...nce d'un\nTel: 05.59.44.38.53 infiltrat en verre dépoli du lobe inférieur gauche compatible avec une pneumopathie interstitielle bien que non spécifique\nExplorations Endoscopies Pas d'épaississement, d'épanchement..."
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},
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"dp_selection": {
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"chosen_index": 0,
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"chosen_term": "Pneumopathie",
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"chosen_code": "J18.9",
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"verdict": "CONFIRMED",
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"evidence": [
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"Score 3.0 — source: regex (section forte)"
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],
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"reason": "Candidat unique",
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"candidates": [
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{
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"index": 0,
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"term": "Pneumopathie",
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"code": "J18.9",
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"source": "regex",
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"is_comorbidity_like": false,
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"is_symptom_like": false,
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"is_act_only": false,
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"section_strength": 3,
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"num_occurrences": 1,
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"score": 3.0,
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"score_details": {
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"section": 3,
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"confidence": 0
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}
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}
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],
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"debug_scores": {
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"top1": 3.0
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}
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},
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"dp_crh_only": {
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"chosen_index": 0,
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"chosen_term": "Pneumopathie",
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"chosen_code": "J18.9",
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"verdict": "CONFIRMED",
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"evidence": [
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"Score 3.0 — source: regex (section forte)"
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],
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"reason": "Candidat unique",
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"candidates": [
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{
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"index": 0,
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"term": "Pneumopathie",
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"code": "J18.9",
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"source": "regex",
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"is_comorbidity_like": false,
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"is_symptom_like": false,
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"is_act_only": false,
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"section_strength": 3,
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"num_occurrences": 1,
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"score": 3.0,
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"score_details": {
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"section": 3,
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"confidence": 0
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}
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}
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],
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"debug_scores": {
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"top1": 3.0
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}
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},
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"dp_final": {
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"chosen_index": 0,
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"chosen_term": "Pneumopathie",
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"chosen_code": "J18.9",
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"verdict": "CONFIRMED",
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"evidence": [
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"Score 3.0 — source: regex (section forte)"
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],
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"reason": "Candidat unique",
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"candidates": [
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{
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"index": 0,
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"term": "Pneumopathie",
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"code": "J18.9",
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"source": "regex",
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"is_comorbidity_like": false,
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"is_symptom_like": false,
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"is_act_only": false,
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"section_strength": 3,
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"num_occurrences": 1,
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"score": 3.0,
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"score_details": {
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"section": 3,
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"confidence": 0
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}
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}
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],
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"debug_scores": {
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"top1": 3.0
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}
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},
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"quality_flags": {
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"rag_status": "error",
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"crh_only_mode": true
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},
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"diagnostics_associes": [],
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"actes_ccam": [
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{
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"texte": "TDM abdominal",
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"code_ccam_suggestion": "ZCQK002",
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"sources_rag": [],
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"validite": "valide",
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"alertes": []
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}
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],
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"antecedents": [],
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"traitements_sortie": [],
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"biologie_cle": [
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{
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"test": "CRP",
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"valeur": "49",
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"valeur_num": 49.0,
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"anomalie": true,
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"quality": "ok",
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"source_page": 2,
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"source_excerpt": "...r\nmédical de fédération Hb14.3, leuco 12.5, plaquettes 257, Na 137, K 3.8, Cl 100, RA 26, créat 84, CRP 49\nChef de Pôle\nDr Emmanuel ELLIE Antalgie\nNeurologue\nrepos\neellie@ch-cotebasque.fr\nCadre de Pôle\nR..."
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},
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{
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"test": "Sodium",
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"valeur": "137",
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"valeur_num": 137.0,
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"anomalie": false,
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"quality": "ok"
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},
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{
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"test": "Potassium",
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"valeur": "3.8",
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"valeur_num": 3.8,
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"anomalie": false,
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"quality": "ok"
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},
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{
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"test": "Chlore",
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"valeur": "100",
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"valeur_num": 100.0,
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"quality": "ok"
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},
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{
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"test": "Plaquettes",
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"valeur": "257",
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"valeur_num": 257.0,
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"anomalie": false,
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"quality": "ok",
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"source_page": 2,
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"source_excerpt": "...logie\nfédération\nTP 87%\nDr Thomas Grellety, coordonnateur\nmédical de fédération Hb14.3, leuco 12.5, plaquettes 257, Na 137, K 3.8, Cl 100, RA 26, créat 84, CRP 49\nChef de Pôle\nDr Emmanuel ELLIE Antalgie\nNeurolo..."
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}
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],
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"biologie_discarded": [],
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"imagerie": [
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{
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"type": "TDM abdominal",
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"conclusion": "des\n[EMAIL_8]\nsibilants bilatéraux.\nDr [MEDECIN_6]\nIl n'y a pas de syndrome d'ingestion évoquant une rupture œsophagienne\nPneumologue\nDESC Cancérologie\n[EMAIL_7] La radio de thorax et le scanner confirme un pneumomédiastin.\nIl n'y a pas de lésion autre retrouvée.\nDr [MEDECIN_7] [PERSONNE_4]\nPneumologue Conduite à tenir :\nMédecin du Sport Pour le pneumomédiastin :\n[EMAIL_6] Oxygène, au repos, traitement antibiotique par céphalosporines de troisième génération.\nDr [MEDECIN_8] Antalgiques\nPneumolog"
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}
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],
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"complications": [
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{
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"texte": "Fièvre",
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"source_page": 1,
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"source_excerpt": "...la maladie\nclethrosne@ch-cotebasque.fr\nToux et rhinorrhée claire depuis une semaine sans notion de fièvre\nDr Laurence MASSE\nCe jour vers 18h douleur basi thoracique transfixiante avec blockpnée associée\nPn..."
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}
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],
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"alertes_codage": [
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"QUALITE DEGRADEE : erreur RAG — codage sans référentiels",
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"CMA niveau 2 : 'Pneumopathie' (J18.9) — sévérité non_evalue",
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"QC: ⚠️ DOSSIER INCOMPLET : Texte tronqué (TDM abdominal, radio thorax, scanner) — impossible de valider la pathologie respiratoire avec certitude",
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"QC: ⚠️ ABSENCE DE JUSTIFICATION : Aucune preuve clinique documentée pour J18.9 (pas de diagnostic médecin explicite, pas de description radiologique complète)",
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"QC: ⚠️ DIAGNOSTIC DIFFÉRENTIEL NON ÉCARTÉ : Les 'sibilants bilatéraux' suggèrent plutôt une BRONCHITE (J20.9) qu'une pneumopathie (J18.9)",
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"QC: ⚠️ COMPLICATION FIÈVRE : Codée comme 'complication' mais non codifiée en diagnostic. À clarifier : fièvre secondaire à la pneumopathie (non codée séparément) ou diagnostic indépendant ?",
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"QC: ⚠️ CONTEXTE CLINIQUE FLOU : Patient jeune (23 ans), durée 6 jours, CRP modérée — profil compatible avec infection virale ou bronchite plutôt que pneumonie bactérienne",
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"QC: ⚠️ MANQUE DE DIAGNOSTIC PRINCIPAL : Aucun diagnostic principal (DP) clairement identifié",
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"RULE-DAS-TO-DP: DP absent → DAS J18.9 (Pneumopathie) promu en DP",
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"DECISIONS[PDF]: 1 ligne(s)",
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"DECISION: diagnostic_principal J18.9 promu en DP (RULE-DAS-TO-DP)",
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"VETOS[PDF]: FAIL (score=70)",
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"VETO-02 [HARD] actes_ccam[0]: Acte ZCQK002 sans preuve exploitable"
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],
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"source_files": [],
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"ghm_estimation": {
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"cmd": "04",
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"cmd_libelle": "Affections de l'appareil respiratoire",
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"type_ghm": "K",
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"severite": 1,
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"ghm_approx": "04K??1",
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"cma_count": 0,
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"cms_count": 0,
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"alertes": []
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},
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"controles_cpam": [],
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"veto_report": {
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"verdict": "FAIL",
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"score_contestabilite": 70,
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"issues": [
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{
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"veto": "VETO-02",
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"severity": "HARD",
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"where": "actes_ccam[0]",
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"message": "Acte ZCQK002 sans preuve exploitable",
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"citation": "Principe de preuve : tout diagnostic/acte doit être étayé par une trace dans le dossier médical (Guide Méthodologique MCO)"
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}
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]
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},
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"completude": {
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"checks": [
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{
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"code": "J18.9",
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"libelle": "Pneumopathie",
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"type_diag": "DP",
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"items": [
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{
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"categorie": "imagerie",
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"element": "Radio/Scanner thoracique",
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"statut": "absent",
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"importance": "obligatoire",
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"impact_cpam": "Imagerie thoracique indispensable pour confirmer une pneumopathie"
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},
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{
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"categorie": "biologie",
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"element": "CRP",
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"statut": "present",
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"valeur": "49",
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"importance": "recommande",
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"impact_cpam": "CRP recommandée pour documenter le syndrome inflammatoire"
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}
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],
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"score": 30,
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"verdict": "indefendable",
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"resume": "0/1 obligatoires, 1/1 recommandés"
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}
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],
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"score_global": 30,
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"verdict_global": "indefendable",
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"documents_presents": [
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"crh"
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],
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"documents_manquants": []
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},
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"processing_time_s": 16.76,
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"metrics": {
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"das_total": 0,
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"das_active": 0,
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"das_excluded": 0,
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"das_removed": 0,
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"das_ruled_out": 0,
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"das_no_code": 0,
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"actes_total": 1,
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"actes_with_code": 1,
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"dp_has_code": true
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},
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"rules_runtime": {
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"router_version": 1,
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"mode": "strict",
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"enabled_packs": [
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"decisions_core",
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"vetos_core"
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],
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"always_on_rules": [],
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"triggers_fired": []
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}
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} |