t2a_v2/output/structured/171_23108560/CRO_23108560_cim10.json

{
  "source_file": "CRO 23108560.pdf",
  "document_type": "crh",
  "sejour": {
    "sexe": "M"
  },
  "diagnostic_principal": {
    "texte": "Insuffisance rénale",
    "cim10_suggestion": "N19",
    "cim10_confidence": "high",
    "cim10_final": "N19",
    "cim10_decision": {
      "action": "PROMOTE_DP",
      "final_code": "N19",
      "reason": "DAS promu en DP (score (2, 3, 3))",
      "needs_info": [],
      "applied_rules": [
        "RULE-DAS-TO-DP"
      ]
    },
    "sources_rag": [],
    "preuves_cliniques": [],
    "source": "regex",
    "source_page": 1,
    "source_excerpt": "...3\nHOLEP\nHistoire Clinique :\n- Patient ayant présenté une rétention aig|e d'urine, responsable d’une insuffisance rénale aig|e.\n- Il est suivi en Néphrologie.\n- Vu l'obstacle important, décision d’énucléation prostatique..."
  },
  "dp_selection": {
    "chosen_index": 0,
    "chosen_term": "Insuffisance rénale",
    "chosen_code": "N19",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 3.0 — source: regex (section forte)"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Insuffisance rénale",
        "code": "N19",
        "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": "Insuffisance rénale",
    "chosen_code": "N19",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 3.0 — source: regex (section forte)"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Insuffisance rénale",
        "code": "N19",
        "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": "Insuffisance rénale",
    "chosen_code": "N19",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 3.0 — source: regex (section forte)"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Insuffisance rénale",
        "code": "N19",
        "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": [],
  "antecedents": [],
  "traitements_sortie": [],
  "biologie_cle": [],
  "biologie_discarded": [],
  "imagerie": [],
  "complications": [],
  "alertes_codage": [
    "QUALITE DEGRADEE : erreur RAG — codage sans référentiels",
    "QC: DAS N19 (Insuffisance rénale) à reconsidérer — Le code N19 (Insuffisance rénale) nécessite une justification clinique précise. L'absence de preuves dans le dossier rend ce codage non pertinent et doit être supprimé.  Un code N19 sans justification est un codage non conforme.",
    "QC: Absence de justification clinique pour le code N19.  Vérifier le dossier clinique pour identifier la présence d'une insuffisance rénale et justifier le codage.",
    "RULE-DAS-TO-DP: DP absent → DAS N19 (Insuffisance rénale) promu en DP",
    "DECISIONS[PDF]: 1 ligne(s)",
    "DECISION: diagnostic_principal N19 promu en DP (RULE-DAS-TO-DP)"
  ],
  "source_files": [],
  "ghm_estimation": {
    "cmd": "11",
    "cmd_libelle": "Affections du rein et des voies urinaires",
    "type_ghm": "M",
    "severite": 1,
    "ghm_approx": "11M??1",
    "cma_count": 0,
    "cms_count": 0,
    "alertes": []
  },
  "controles_cpam": [],
  "veto_report": {
    "verdict": "PASS",
    "score_contestabilite": 100,
    "issues": []
  },
  "completude": {
    "checks": [
      {
        "code": "N19",
        "libelle": "Insuffisance rénale",
        "type_diag": "DP",
        "items": [
          {
            "categorie": "biologie",
            "element": "Créatinine",
            "statut": "absent",
            "importance": "obligatoire",
            "impact_cpam": "Créatinine obligatoire pour confirmer une insuffisance rénale"
          },
          {
            "categorie": "biologie",
            "element": "DFG",
            "statut": "absent",
            "importance": "recommande",
            "impact_cpam": "Permet de stadifier l'IR selon KDIGO"
          },
          {
            "categorie": "biologie",
            "element": "Urée",
            "statut": "absent",
            "importance": "recommande",
            "impact_cpam": "Élément complémentaire de la fonction rénale"
          }
        ],
        "score": 0,
        "verdict": "indefendable",
        "resume": "0/1 obligatoires, 0/2 recommandés"
      }
    ],
    "score_global": 0,
    "verdict_global": "indefendable",
    "documents_presents": [
      "crh"
    ],
    "documents_manquants": []
  },
  "processing_time_s": 288.92,
  "metrics": {
    "das_total": 0,
    "das_active": 0,
    "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": []
  }
}