t2a_v2/output/structured/12_23084754/CRO_23084754_cim10.json

{
  "source_file": "CRO 23084754.pdf",
  "document_type": "crh",
  "sejour": {
    "sexe": "F"
  },
  "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": "...GLET\nMadame MARIE-THEREZE AGUIRRE\nNée le 12/02/1944\nCHOLECYSTECTOMIE SOUS COELIOSCOPIE\nDIAGNOSTIC : Cholécystite aiguë. Patiente admise aux urgences sur des douleurs fébriles de l’hypochondre.\ncholécystite.\nCompte rend..."
  },
  "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": "...ntrôle du moignon cystique restant par trois clips (HEMOLOCK 10) Section\nentre trois (HEMOLOCK 10). Cholécystectomie rétrograde. Extériorisation de la vésicule dans un endosac intr\nde 10 mm.\nVérification du lit vésic..."
    },
    {
      "texte": "Cholangiographie peropératoire",
      "code_ccam_suggestion": "HHHE002",
      "sources_rag": [],
      "validite": "non_verifie",
      "alertes": []
    }
  ],
  "antecedents": [],
  "traitements_sortie": [],
  "biologie_cle": [],
  "biologie_discarded": [],
  "imagerie": [],
  "complications": [],
  "alertes_codage": [
    "QUALITE DEGRADEE : erreur RAG — codage sans référentiels",
    "CCAM HHHE002 (Cholangiographie peropératoire) : code absent du dictionnaire CCAM V81",
    "CMA niveau 3 : 'Cholécystite aiguë' (K81.0) — sévérité severe, marqueurs : aigue",
    "QC: DAS K81.0 (Cholécystite aiguë) à reconsidérer — ABSENCE TOTALE DE JUSTIFICATION ET DE PREUVE CLINIQUE. Le codage indique explicitement 'Preuves: aucune'. Un diagnostic de cholécystite aiguë ne peut être codé sans éléments cliniques, biologiques ou d'imagerie documentés (douleur de l'hypochondre droit, signes de Murphy, élévation des marqueurs inflammatoires, échographie/scanner montrant épaississement pariétal, épanchement péri-vésiculaire, etc.). Ce code ne peut pas être maintenu.",
    "QC: ⚠️ CODAGE NON JUSTIFIÉ : Aucune preuve clinique fournie pour le diagnostic principal",
    "QC: ⚠️ DOSSIER INCOMPLET : Absence totale de documentation clinique, biologique ou radiologique",
    "QC: ⚠️ RISQUE QUALITÉ PMSI : Codage sans fondement = risque de facturation injustifiée et de non-conformité",
    "QC: 📋 ACTION REQUISE : Demander au clinicien de fournir les éléments justificatifs ou de corriger le diagnostic",
    "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)",
    "VETOS[PDF]: FAIL (score=70)",
    "VETO-02 [HARD] actes_ccam[1]: Acte HHHE002 sans preuve exploitable"
  ],
  "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": "FAIL",
    "score_contestabilite": 70,
    "issues": [
      {
        "veto": "VETO-02",
        "severity": "HARD",
        "where": "actes_ccam[1]",
        "message": "Acte HHHE002 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": "HMFC004, HHHE002",
        "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": 9.75,
  "metrics": {
    "das_total": 0,
    "das_active": 0,
    "das_excluded": 0,
    "das_removed": 0,
    "das_ruled_out": 0,
    "das_no_code": 0,
    "actes_total": 2,
    "actes_with_code": 2,
    "dp_has_code": true
  },
  "rules_runtime": {
    "router_version": 1,
    "mode": "strict",
    "enabled_packs": [
      "decisions_core",
      "vetos_core"
    ],
    "always_on_rules": [],
    "triggers_fired": []
  }
}