13fe9fa666
Résultats de re-traitement pipeline v2 sur 261 dossiers. Co-Authored-By: Claude Opus 4.6 <noreply@anthropic.com>
347 lines
13 KiB
JSON
347 lines
13 KiB
JSON
{
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"source_file": "",
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"document_type": "trackare",
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"sejour": {
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"sexe": "F",
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"age": 55,
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"date_entree": "27/03/2023",
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"date_sortie": "31/03/2023",
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"duree_sejour": 4,
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"imc": 22.827,
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"poids": 50.0,
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"taille": 148.0
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},
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"diagnostic_principal": {
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"texte": "Hypertension artérielle",
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"cim10_suggestion": "I10",
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"cim10_confidence": "high",
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"cim10_final": "I10",
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"cim10_decision": {
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"action": "PROMOTE_DP",
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"final_code": "I10",
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"reason": "DAS promu en DP (score (2, 3, 3))",
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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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},
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"dp_final": {
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"verdict": "REVIEW",
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"evidence": [],
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"reason": "Aucun DP disponible",
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"candidates": []
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},
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"quality_flags": {
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"no_dp_source": true
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},
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"diagnostics_associes": [
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{
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"texte": "Insuffisance rénale",
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"cim10_suggestion": "N19",
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"cim10_confidence": "high",
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"cim10_final": "N19",
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"sources_rag": [],
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"preuves_cliniques": [],
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"niveau_severite": "non_evalue",
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"niveau_cma": 1,
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"source": "regex",
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"source_page": 14,
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"source_excerpt": "...SAT 171 U/l Hémolysé U/l 96 U/l\nNon-applicable en cas Non-applicable en cas Non-applicable en cas\nd'insuffisance rénale d'insuffisance rénale d'insuffisance rénale\naigue. Estimation du aigue. Estimation du aigue. Estima..."
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},
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{
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"texte": "Cytolyse hépatique",
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"cim10_suggestion": "R94.5",
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"cim10_confidence": "medium",
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"cim10_final": "R94.5",
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"justification": "ASAT 171 et ALAT 175 (normes 0-40) sont significativement élevées, témoignant d'une atteinte hépatique ayant mobilisé des ressources diagnostiques et thérapeutiques pendant le séjour",
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"sources_rag": [],
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"preuves_cliniques": [],
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"niveau_severite": "non_evalue",
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"niveau_cma": 1,
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"source": "llm_das"
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}
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],
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"actes_ccam": [
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{
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"texte": "Cholécystectomie",
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"code_ccam_suggestion": "HMFC004",
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"sources_rag": [],
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"validite": "valide",
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"alertes": [],
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"source_page": 1,
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"source_excerpt": "...on du kyste à l’ultracision 5 mm avant le parenchyme hépatique permettant d’enlever les ¾ du kyste.\nCholécystectomie mono bloc avec ligature de l’artère cystique entre clips Hemolock et section du cystique ent\nLe fon..."
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}
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],
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"antecedents": [],
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"traitements_sortie": [
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{
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"medicament": "ML INJ SER",
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"source_page": 4,
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"source_excerpt": "...Sortie\nVoie d`administration: SOUS-CUTANEE\nStatut des prescriptions: Signé\nLOVENOX 4000UI\n1\nAXa/0,4ML INJ SER\nSERINGUE(S) - Presc. de Sortie 28/03/2023 08:46 Anaïs CARRAZÉ\n+S [2] SERINGUE(S)\nPREREMPLIE(S)\nPRER..."
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}
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],
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"biologie_cle": [
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{
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"test": "CRP",
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"valeur": "23",
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"valeur_num": 23.0,
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"anomalie": true,
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"quality": "ok",
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"source_page": 4,
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"source_excerpt": "...023\n30/03/2023 12:48 Créatinine sang ( dosage ) DR. Ute DURANTEAU\n13:14\n30/03/2023\n30/03/2023 12:48 CRP sang ( dosage ) DR. Ute DURANTEAU\n13:14\nBilan hépatique ( ASAT, ALAT, 30/03/2023\n30/03/2023 12:48 D..."
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},
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{
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"test": "ASAT",
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"valeur": "171",
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"valeur_num": 171.0,
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"anomalie": true,
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"quality": "ok",
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"source_page": 4,
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"source_excerpt": "...ription Docteur Note\ncollection\n28/03/2023 08:46 Num +Formule +Plaq Anaïs CARRAZÉ\nBilan hépatique ( ASAT, ALAT,\n28/03/2023 08:46 Anaïs CARRAZÉ\nGGT, PAL, bilirubine )\nPièce opératoire ( Atlantic- 28/03/202..."
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},
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{
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"test": "ALAT",
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"valeur": "175",
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"valeur_num": 175.0,
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"anomalie": true,
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"quality": "ok",
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"source_page": 4,
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"source_excerpt": "...n Docteur Note\ncollection\n28/03/2023 08:46 Num +Formule +Plaq Anaïs CARRAZÉ\nBilan hépatique ( ASAT, ALAT,\n28/03/2023 08:46 Anaïs CARRAZÉ\nGGT, PAL, bilirubine )\nPièce opératoire ( Atlantic- 28/03/2023\n28/0..."
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},
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{
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"test": "Sodium",
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"valeur": "139",
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"valeur_num": 139.0,
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"anomalie": false,
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"quality": "ok",
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"source_page": 15,
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"source_excerpt": "...Hémoglobine 12,1 g/dl 12,7 g/dl\nVGM 89,1 fl 89,8 fl\nTCMH 30,0 pg 30,2 pg\nCCMH 33,6 g/dl 33,7 g/dl\nSodium 139 mmol/l 136 mmol/l 141 mmol/l\nPrélèvement non\nNon conformité validé initialement par\nService\nPla..."
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},
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{
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"test": "Potassium",
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"valeur": "4.7",
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"valeur_num": 4.7,
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"anomalie": false,
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"quality": "ok",
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"source_page": 14,
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"source_excerpt": "...Sysmex) XN (Sysmex)\nHématocrite (%) 36,0 % 37,7 %\nIndice de distribution des\n12,1 % 12,1 %\nhématies\nPotassium 4,7 mmol/l Hémolysé mmol/l 4,3 mmol/l\nLeucocytes 11,76 10.9/l 11,08 10.9/l\nHématies 4,04 10.12/l (t..."
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},
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{
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"test": "Chlore",
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"valeur": "103",
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"valeur_num": 103.0,
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"quality": "ok",
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"source_page": 14,
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"source_excerpt": "...olysé U/l 76 U/l\nEstimation du DFG (CKD-\n103 ml/mn/1.73 m2 110 ml/mn/1.73 m2 101 ml/mn/1.73 m2\nEPI)\nChlore 103 mmol/l 105 mmol/l 106 mmol/l\nCréatinine 53 µmol/l 44 µmol/l 56 µmol/l\nCRP 23 mg/l 22 mg/l 7 mg/..."
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},
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{
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"test": "Hémoglobine",
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"valeur": "12.1",
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"valeur_num": 12.1,
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"anomalie": false,
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"quality": "ok",
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"source_page": 15,
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"source_excerpt": "...HIRURGIE VISC.A2 ) - Taille: 148 cm - Poids: 50 kg - IMC: 22.827\nLe 31/03/2023 13:43 Page 14 de 15\n\nHémoglobine 12,1 g/dl 12,7 g/dl\nVGM 89,1 fl 89,8 fl\nTCMH 30,0 pg 30,2 pg\nCCMH 33,6 g/dl 33,7 g/dl\nSodium 139 mm..."
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},
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{
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"test": "VGM",
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"valeur": "89.1",
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"valeur_num": 89.1,
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"quality": "ok",
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"source_page": 15,
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"source_excerpt": "...cm - Poids: 50 kg - IMC: 22.827\nLe 31/03/2023 13:43 Page 14 de 15\n\nHémoglobine 12,1 g/dl 12,7 g/dl\nVGM 89,1 fl 89,8 fl\nTCMH 30,0 pg 30,2 pg\nCCMH 33,6 g/dl 33,7 g/dl\nSodium 139 mmol/l 136 mmol/l 141 mmol..."
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},
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{
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"test": "Plaquettes",
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"valeur": "303",
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"valeur_num": 303.0,
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"anomalie": false,
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"quality": "ok",
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"source_page": 15,
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"source_excerpt": "...ium 139 mmol/l 136 mmol/l 141 mmol/l\nPrélèvement non\nNon conformité validé initialement par\nService\nPlaquettes 303 10.9/l 291 10.9/l\nDr. Marie-Laure\nValidation et diffusion sous la Dr. Anne Christine\nCURUTCHET..."
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},
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{
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"test": "Leucocytes",
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"valeur": "11.76",
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"valeur_num": 11.76,
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"anomalie": true,
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"quality": "ok",
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"source_page": 14,
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"source_excerpt": "...%\nIndice de distribution des\n12,1 % 12,1 %\nhématies\nPotassium 4,7 mmol/l Hémolysé mmol/l 4,3 mmol/l\nLeucocytes 11,76 10.9/l 11,08 10.9/l\nHématies 4,04 10.12/l (t/l) 4,20 10.12/l (t/l)\nPatient: ABELLARD EYQUEM N..."
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},
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{
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"test": "Créatinine",
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"valeur": "53",
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"valeur_num": 53.0,
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"anomalie": false,
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"quality": "ok",
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"source_page": 4,
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"source_excerpt": "...9/03/2023\n29/03/2023 07:00 Ionogramme ( Na, K, CL ) Anaïs CARRAZÉ\n06:01\n29/03/2023\n29/03/2023 07:00 Créatinine sang ( dosage ) Anaïs CARRAZÉ\n06:01\n30/03/2023\n30/03/2023 11:33 Ionogramme ( Na, K, CL ) DR. Ute DU..."
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}
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],
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"biologie_discarded": [],
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"imagerie": [],
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"complications": [
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{
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"texte": "Infection",
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"source_page": 5,
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"source_excerpt": "...al Loïc JOEST\nIDENTIFICATION 08:00\n28/03/2023\nDEPILATION Réalisé - à 08h Normal Loïc JOEST\n08:00\nDESINFECTION\n1 Semaine - Matin 28/03/2023\nENVIRONNEMENT Réalisé Loïc JOEST\n[8h] Normal 08:00\nPATIENT\nHABILLAGE :..."
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}
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],
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"alertes_codage": [
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"FUSION: 2 documents fusionnés",
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"QUALITE DEGRADEE : erreur RAG — codage sans référentiels",
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"NUKE-3 REVIEW: DP ambigu — Aucun candidat DP identifié",
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"QC: DAS I10 (Hypertension artérielle) à reconsidérer — AUCUNE preuve clinique d'HTA dans le dossier. Pas d'antécédent mentionné, pas de traitement antihypertenseur, pas de mesure tensionnelle rapportée. Codage injustifié = risque de sur-codage.",
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"QC: DAS N19 (Insuffisance rénale) à reconsidérer — Créatinine 53 µmol/L est NORMALE (normes 50-120). Pas d'insuffisance rénale. Codage contraire aux données biologiques = erreur manifeste.",
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"QC: ⚠️ CODAGE TRÈS PROBLÉMATIQUE : 2 codes sur 3 sans justification clinique (I10, N19)",
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"QC: ⚠️ Contradiction flagrante : N19 codée alors que créatinine normale",
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"QC: ⚠️ Manque diagnostic étiologique : cytolyse hépatique présente mais cause non codée (hépatite ? infection ? toxique ?)",
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"QC: ⚠️ Complication mentionnée (infection) mais non codée → risque de sous-codage du GHM",
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"QC: ⚠️ CRP 23 + leucocytes 11.76 + cytolyse hépatique = contexte infectieux/inflammatoire : chercher diagnostic principal (hépatite virale, bactérienne, etc.)",
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"QC: ⚠️ Justification du code R94.5 incomplète : « ayant mobilisé des ressources » n'est pas un critère de codage PMSI",
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"RULE-DAS-TO-DP: DP absent → DAS I10 (Hypertension artérielle) promu en DP",
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"DECISIONS[PDF]: 1 ligne(s)",
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"Aucun DP extrait (ni Trackare ni CRH)",
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"DECISIONS[FINAL]: 1 ligne(s)",
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"DECISION: diagnostic_principal I10 promu en DP (RULE-DAS-TO-DP)",
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"VETOS[FINAL]: FAIL (score=20)",
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"VETO-02 [HARD] diagnostic_principal: DP I10 sans preuve exploitable",
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"VETO-02 [MEDIUM] diagnostics_associes[1]: DAS R94.5 sans preuve exploitable",
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"VETO-09 [LOW] diagnostics_associes[0]: IR N19 à confirmer (créat=53.0)",
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"VETO-12 [HARD] diagnostic_principal: DP I10 en high sans preuve"
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],
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"source_files": [
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"CRO 23028431.pdf",
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"trackare-05010445-23028431_05010445_23028431.pdf"
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],
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"ghm_estimation": {
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"cmd": "05",
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"cmd_libelle": "Affections de l'appareil circulatoire",
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"type_ghm": "C",
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"severite": 1,
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"ghm_approx": "05C??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": 20,
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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": "diagnostic_principal",
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"message": "DP I10 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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"veto": "VETO-02",
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"severity": "MEDIUM",
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"where": "diagnostics_associes[1]",
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"message": "DAS R94.5 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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"veto": "VETO-09",
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"severity": "LOW",
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"where": "diagnostics_associes[0]",
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"message": "IR N19 à confirmer (créat=53.0)"
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},
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{
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"veto": "VETO-12",
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"severity": "HARD",
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"where": "diagnostic_principal",
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"message": "DP I10 en high sans preuve"
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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": "N19",
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"libelle": "Insuffisance rénale",
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"type_diag": "DAS",
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"items": [
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{
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"categorie": "biologie",
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"element": "Créatinine",
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"statut": "present_non_confirme",
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"valeur": "53",
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"importance": "obligatoire",
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"impact_cpam": "Créatinine obligatoire pour confirmer une insuffisance rénale",
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"confirmation_detail": "Créatinine ≤ 120 µmol/L : IR non confirmée biologiquement"
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},
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{
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"categorie": "biologie",
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"element": "DFG",
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"statut": "absent",
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"importance": "recommande",
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"impact_cpam": "Permet de stadifier l'IR selon KDIGO"
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},
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{
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"categorie": "biologie",
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"element": "Urée",
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"statut": "absent",
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"importance": "recommande",
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"impact_cpam": "Élément complémentaire de la fonction rénale"
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}
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],
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"score": 17,
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"verdict": "fragile",
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"resume": "1/1 obligatoires, 0/2 recommandés"
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},
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{
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"code": "HMFC004",
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"libelle": "Acte chirurgical nécessitant un CRO",
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"type_diag": "Acte",
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"items": [
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{
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"categorie": "document",
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"element": "CRO",
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"statut": "present",
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"importance": "obligatoire",
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"impact_cpam": "Compte-rendu opératoire obligatoire pour tout acte chirurgical"
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}
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],
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"score": 100,
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"verdict": "defendable",
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"resume": "1/1 obligatoires"
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}
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],
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"score_global": 58,
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"verdict_global": "fragile",
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"documents_presents": [
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"cro",
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"trackare"
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],
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"documents_manquants": []
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},
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"metrics": {
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"das_total": 2,
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"das_active": 2,
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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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} |