360 lines
12 KiB
JSON
360 lines
12 KiB
JSON
{
|
||
"source_file": "anapath 55_23246490.pdf",
|
||
"document_type": "crh",
|
||
"sejour": {},
|
||
"diagnostic_principal": {
|
||
"texte": "Cholecystite",
|
||
"cim10_suggestion": "K81.9",
|
||
"cim10_confidence": "low",
|
||
"cim10_final": "K81.9",
|
||
"justification": "Cholecystite sans précision, correspondant au diagnostic initial et respectant l'absence de spécification.",
|
||
"raisonnement": "ANALYSE CLINIQUE :\nLa cholecystite est une inflammation de la vésicule biliaire. Elle peut être aiguë ou chronique, et souvent associée à la présence de calculs biliaires (cholélithiase).\n\nCODES CANDIDATS :\nK80.0, K80.1, K80.4, K81.1, K81.9\n\nDISCRIMINATION :\nLe diagnostic est simplement \"Cholecystite\" sans précision sur l'acuité (aiguë ou chronique) ni la présence de calculs. K81.1 (cholécystite chronique) et K81.9 (cholecystite sans précision) sont donc des options. K81.9 est le code le plus approprié car il reflète le manque de spécificité du diagnostic initial. Les codes K80.x impliquent la présence de calculs biliaires, ce qui n'est pas précisé dans le diagnostic.\n\nREGLE PMSI :\nEn tant que DP, le code doit refléter la raison principale de l'hospitalisation. L'absence de précision nécessite le code le plus général possible, tout en restant pertinent.",
|
||
"sources_rag": [
|
||
{
|
||
"document": "cim10",
|
||
"page": 494,
|
||
"code": "K81.1",
|
||
"extrait": "K81.1 Cholécystite chronique"
|
||
},
|
||
{
|
||
"document": "cim10",
|
||
"page": 495,
|
||
"code": "K82.4",
|
||
"extrait": "K82.4 Choléstérolose de la vésicule biliaire\nVésicule fraise"
|
||
},
|
||
{
|
||
"document": "cim10",
|
||
"page": 494,
|
||
"code": "K80.1",
|
||
"extrait": "K80.1 Calcul de la vésicule biliaire avec une autre forme de cholécystite\nCholécystite avec cholélithiase SAI\nTout état mentionné en K80.2 avec cholécystite (chronique)"
|
||
},
|
||
{
|
||
"document": "cim10",
|
||
"page": 494,
|
||
"code": "K80.0",
|
||
"extrait": "K80.0 Calcul de la vésicule biliaire avec cholécystite aigüe\nTout état mentionné en K80.2 avec cholécystite aigüe"
|
||
},
|
||
{
|
||
"document": "cim10",
|
||
"page": 94,
|
||
"code": "A00",
|
||
"extrait": "A00 Choléra\nA00.0 À Vibrio cholerae 01, biovar cholerae\nCholéra classique\nA00.1 À Vibrio cholerae 01, biovar El Tor\nCholéra El Tor\nClassification Internationale des Maladies CIM-10-FR 2026\nA00.9 Cholé"
|
||
},
|
||
{
|
||
"document": "cim10",
|
||
"page": 494,
|
||
"code": "K80.4",
|
||
"extrait": "K80.4 Calcul des canaux biliaires avec cholécystite\nTout état mentionné en K80.5 avec cholécystite (avec angiocholite)"
|
||
},
|
||
{
|
||
"document": "cim10_alpha",
|
||
"page": 995,
|
||
"code": "A00",
|
||
"extrait": "001 Choléra → A00"
|
||
},
|
||
{
|
||
"document": "cim10_alpha",
|
||
"page": 984,
|
||
"code": "A00",
|
||
"extrait": "1-002 Choléra → A00"
|
||
},
|
||
{
|
||
"document": "cim10",
|
||
"page": 493,
|
||
"code": "K76.1",
|
||
"extrait": "K76.1 Congestion passive chronique du foie\nCirrhose du foie (dite) cardiaque\nSclérose du foie d'origine cardiaque"
|
||
},
|
||
{
|
||
"document": "cim10",
|
||
"page": 494,
|
||
"code": "K81.9",
|
||
"extrait": "K81.9 Cholécystite, sans précision\nClassification Internationale des Maladies CIM-10-FR 2026"
|
||
}
|
||
],
|
||
"preuves_cliniques": [],
|
||
"est_cma": true,
|
||
"niveau_severite": "non_evalue",
|
||
"niveau_cma": 2,
|
||
"source": "edsnlp",
|
||
"source_page": 1,
|
||
"source_excerpt": "...nucléaires.\nLe reste de la paroi est souvent œdémateux.\nPas de suspicion de malignité.\nCONCLUSION :\nCHOLECYSTITE SUBAIGUE LITHIASIQUE.\nDr. Michael TARIS\nAdicap : Validé électroniquement le 02/01/2024 08:43\nS.E.L...."
|
||
},
|
||
"dp_selection": {
|
||
"chosen_index": 0,
|
||
"chosen_term": "Cholecystite",
|
||
"chosen_code": "K81.9",
|
||
"confidence": "high",
|
||
"verdict": "CONFIRMED",
|
||
"evidence": [
|
||
"Score 9.0 — source: edsnlp",
|
||
"Conclusion: «CHOLECYSTITE SUBAIGUE LITHIASIQUE.\nDr. Michael TARIS\nAdicap : Validé électroniquement le 02/01/2024 08:43\nS.E.L.A.R.L. au capital de 344 403 € - 388 853 707 RCS BAYONNE 1/1\nATLANTIC PATHOLOGIE – 14 allée de Bordenave – 64990 SAINT PIERRE D’»",
|
||
"Delta +3.0 vs Lithiase de la vésicule biliaire (K81.0)"
|
||
],
|
||
"reason": "Écart score 3.0 >= seuil 3.0",
|
||
"candidates": [
|
||
{
|
||
"index": 0,
|
||
"term": "Cholecystite",
|
||
"code": "K81.9",
|
||
"confidence": "high",
|
||
"source": "edsnlp",
|
||
"is_comorbidity_like": false,
|
||
"is_symptom_like": false,
|
||
"is_act_only": false,
|
||
"section_strength": 2,
|
||
"num_occurrences": 3,
|
||
"score": 9.0,
|
||
"score_details": {
|
||
"section": 2,
|
||
"confidence": 3,
|
||
"occurrences": 2,
|
||
"diag_section_bonus": 2
|
||
}
|
||
},
|
||
{
|
||
"index": 1,
|
||
"term": "Lithiase de la vésicule biliaire",
|
||
"code": "K81.0",
|
||
"confidence": "high",
|
||
"source": "llm_das",
|
||
"is_comorbidity_like": false,
|
||
"is_symptom_like": false,
|
||
"is_act_only": false,
|
||
"section_strength": 1,
|
||
"num_occurrences": 3,
|
||
"score": 6.0,
|
||
"score_details": {
|
||
"section": 1,
|
||
"confidence": 3,
|
||
"occurrences": 2
|
||
}
|
||
},
|
||
{
|
||
"index": 2,
|
||
"term": "Inflammation chronique de la vésicule biliaire",
|
||
"code": "K81.1",
|
||
"confidence": "high",
|
||
"source": "llm_das",
|
||
"is_comorbidity_like": false,
|
||
"is_symptom_like": false,
|
||
"is_act_only": false,
|
||
"section_strength": 1,
|
||
"num_occurrences": 3,
|
||
"score": 6.0,
|
||
"score_details": {
|
||
"section": 1,
|
||
"confidence": 3,
|
||
"occurrences": 2
|
||
}
|
||
}
|
||
],
|
||
"debug_scores": {
|
||
"top1": 9.0,
|
||
"top2": 6.0,
|
||
"delta": 3.0
|
||
}
|
||
},
|
||
"dp_crh_only": {
|
||
"chosen_index": 0,
|
||
"chosen_term": "Cholecystite",
|
||
"chosen_code": "K81.9",
|
||
"confidence": "high",
|
||
"verdict": "CONFIRMED",
|
||
"evidence": [
|
||
"Score 9.0 — source: edsnlp",
|
||
"Conclusion: «CHOLECYSTITE SUBAIGUE LITHIASIQUE.\nDr. Michael TARIS\nAdicap : Validé électroniquement le 02/01/2024 08:43\nS.E.L.A.R.L. au capital de 344 403 € - 388 853 707 RCS BAYONNE 1/1\nATLANTIC PATHOLOGIE – 14 allée de Bordenave – 64990 SAINT PIERRE D’»",
|
||
"Delta +3.0 vs Lithiase de la vésicule biliaire (K81.0)"
|
||
],
|
||
"reason": "Écart score 3.0 >= seuil 3.0",
|
||
"candidates": [
|
||
{
|
||
"index": 0,
|
||
"term": "Cholecystite",
|
||
"code": "K81.9",
|
||
"confidence": "high",
|
||
"source": "edsnlp",
|
||
"is_comorbidity_like": false,
|
||
"is_symptom_like": false,
|
||
"is_act_only": false,
|
||
"section_strength": 2,
|
||
"num_occurrences": 3,
|
||
"score": 9.0,
|
||
"score_details": {
|
||
"section": 2,
|
||
"confidence": 3,
|
||
"occurrences": 2,
|
||
"diag_section_bonus": 2
|
||
}
|
||
},
|
||
{
|
||
"index": 1,
|
||
"term": "Lithiase de la vésicule biliaire",
|
||
"code": "K81.0",
|
||
"confidence": "high",
|
||
"source": "llm_das",
|
||
"is_comorbidity_like": false,
|
||
"is_symptom_like": false,
|
||
"is_act_only": false,
|
||
"section_strength": 1,
|
||
"num_occurrences": 3,
|
||
"score": 6.0,
|
||
"score_details": {
|
||
"section": 1,
|
||
"confidence": 3,
|
||
"occurrences": 2
|
||
}
|
||
},
|
||
{
|
||
"index": 2,
|
||
"term": "Inflammation chronique de la vésicule biliaire",
|
||
"code": "K81.1",
|
||
"confidence": "high",
|
||
"source": "llm_das",
|
||
"is_comorbidity_like": false,
|
||
"is_symptom_like": false,
|
||
"is_act_only": false,
|
||
"section_strength": 1,
|
||
"num_occurrences": 3,
|
||
"score": 6.0,
|
||
"score_details": {
|
||
"section": 1,
|
||
"confidence": 3,
|
||
"occurrences": 2
|
||
}
|
||
}
|
||
],
|
||
"debug_scores": {
|
||
"top1": 9.0,
|
||
"top2": 6.0,
|
||
"delta": 3.0
|
||
}
|
||
},
|
||
"dp_final": {
|
||
"chosen_index": 0,
|
||
"chosen_term": "Cholecystite",
|
||
"chosen_code": "K81.9",
|
||
"confidence": "high",
|
||
"verdict": "CONFIRMED",
|
||
"evidence": [
|
||
"Score 9.0 — source: edsnlp",
|
||
"Conclusion: «CHOLECYSTITE SUBAIGUE LITHIASIQUE.\nDr. Michael TARIS\nAdicap : Validé électroniquement le 02/01/2024 08:43\nS.E.L.A.R.L. au capital de 344 403 € - 388 853 707 RCS BAYONNE 1/1\nATLANTIC PATHOLOGIE – 14 allée de Bordenave – 64990 SAINT PIERRE D’»",
|
||
"Delta +3.0 vs Lithiase de la vésicule biliaire (K81.0)"
|
||
],
|
||
"reason": "Écart score 3.0 >= seuil 3.0",
|
||
"candidates": [
|
||
{
|
||
"index": 0,
|
||
"term": "Cholecystite",
|
||
"code": "K81.9",
|
||
"confidence": "high",
|
||
"source": "edsnlp",
|
||
"is_comorbidity_like": false,
|
||
"is_symptom_like": false,
|
||
"is_act_only": false,
|
||
"section_strength": 2,
|
||
"num_occurrences": 3,
|
||
"score": 9.0,
|
||
"score_details": {
|
||
"section": 2,
|
||
"confidence": 3,
|
||
"occurrences": 2,
|
||
"diag_section_bonus": 2
|
||
}
|
||
},
|
||
{
|
||
"index": 1,
|
||
"term": "Lithiase de la vésicule biliaire",
|
||
"code": "K81.0",
|
||
"confidence": "high",
|
||
"source": "llm_das",
|
||
"is_comorbidity_like": false,
|
||
"is_symptom_like": false,
|
||
"is_act_only": false,
|
||
"section_strength": 1,
|
||
"num_occurrences": 3,
|
||
"score": 6.0,
|
||
"score_details": {
|
||
"section": 1,
|
||
"confidence": 3,
|
||
"occurrences": 2
|
||
}
|
||
},
|
||
{
|
||
"index": 2,
|
||
"term": "Inflammation chronique de la vésicule biliaire",
|
||
"code": "K81.1",
|
||
"confidence": "high",
|
||
"source": "llm_das",
|
||
"is_comorbidity_like": false,
|
||
"is_symptom_like": false,
|
||
"is_act_only": false,
|
||
"section_strength": 1,
|
||
"num_occurrences": 3,
|
||
"score": 6.0,
|
||
"score_details": {
|
||
"section": 1,
|
||
"confidence": 3,
|
||
"occurrences": 2
|
||
}
|
||
}
|
||
],
|
||
"debug_scores": {
|
||
"top1": 9.0,
|
||
"top2": 6.0,
|
||
"delta": 3.0
|
||
}
|
||
},
|
||
"quality_flags": {
|
||
"crh_only_mode": true
|
||
},
|
||
"diagnostics_associes": [],
|
||
"actes_ccam": [],
|
||
"antecedents": [],
|
||
"traitements_sortie": [],
|
||
"biologie_cle": [],
|
||
"biologie_discarded": [],
|
||
"imagerie": [],
|
||
"complications": [],
|
||
"alertes_codage": [
|
||
"2 CMA probables détectées — impact potentiel sur le niveau de sévérité GHM",
|
||
"CMA niveau 3 : 'Lithiase de la vésicule biliaire' (K81.0) — sévérité severe, marqueurs : aigue",
|
||
"CMA niveau 2 : 'Inflammation chronique de la vésicule biliaire' (K81.1) — sévérité leger, marqueurs : chronique",
|
||
"QC: DP K81.9 confiance high→low — Le code K81.9 (Cholecystite, non précisée) est trop général. Sans dossier clinique, il est impossible de déterminer la nature exacte de la cholécystite (aiguë, chronique, lithiasique, alithiasique, complications...). Il est impératif d'obtenir plus d'informations du dossier clinique pour choisir un code plus précis. Si aucune information supplémentaire n'est disponible, il faudrait envisager un code plus général comme K81.1 (Cholecystite aiguë) ou K81.8 (Autres formes spécifiées de cholécystite) selon le contexte clinique.",
|
||
"QC: L'absence de dossier clinique rend l'évaluation du codage extrêmement difficile. Un codage précis nécessite une revue approfondie du dossier médical.",
|
||
"QC: Le code K81.9 est un code de dernier recours. Il est crucial de rechercher des informations plus spécifiques dans le dossier clinique pour un codage plus précis et conforme aux directives PMSI."
|
||
],
|
||
"source_files": [],
|
||
"ghm_estimation": {
|
||
"cmd": "07",
|
||
"cmd_libelle": "Affections hépatobiliaires et pancréatiques",
|
||
"type_ghm": "M",
|
||
"severite": 1,
|
||
"ghm_approx": "07M??1",
|
||
"cma_count": 0,
|
||
"cms_count": 0,
|
||
"alertes": []
|
||
},
|
||
"controles_cpam": [],
|
||
"processing_time_s": 14.66,
|
||
"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": []
|
||
}
|
||
} |