t2a_v2/output/structured/189_23138778/BACTERIO_23138778_cim10.json

{
  "source_file": "BACTERIO 23138778.pdf",
  "document_type": "crh",
  "sejour": {},
  "diagnostic_principal": {
    "texte": "Bactériurie significative à Escherichia coli",
    "cim10_suggestion": "N39.0",
    "cim10_confidence": "low",
    "cim10_final": "N39.0",
    "cim10_decision": {
      "action": "PROMOTE_DP",
      "final_code": "N39.0",
      "reason": "DAS promu en DP (score (2, 1, 4))",
      "needs_info": [],
      "applied_rules": [
        "RULE-DAS-TO-DP"
      ]
    },
    "justification": "Le compte-rendu de microbiologie confirme une bactériurie significative (1.10*4 UFC/mL d'Escherichia coli) avec absence de leucocyturie, nécessitant une prise en charge thérapeutique et un suivi biologique pendant le séjour.",
    "sources_rag": [],
    "preuves_cliniques": [],
    "source": "llm_das"
  },
  "dp_selection": {
    "chosen_index": 0,
    "chosen_term": "Bactériurie significative à Escherichia coli",
    "chosen_code": "N39.0",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 1.0 — source: llm_das"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Bactériurie significative à Escherichia coli",
        "code": "N39.0",
        "source": "llm_das",
        "is_comorbidity_like": false,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 1,
        "num_occurrences": 1,
        "score": 1.0,
        "score_details": {
          "section": 1,
          "confidence": 0
        }
      }
    ],
    "debug_scores": {
      "top1": 1.0
    }
  },
  "dp_crh_only": {
    "chosen_index": 0,
    "chosen_term": "Bactériurie significative à Escherichia coli",
    "chosen_code": "N39.0",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 1.0 — source: llm_das"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Bactériurie significative à Escherichia coli",
        "code": "N39.0",
        "source": "llm_das",
        "is_comorbidity_like": false,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 1,
        "num_occurrences": 1,
        "score": 1.0,
        "score_details": {
          "section": 1,
          "confidence": 0
        }
      }
    ],
    "debug_scores": {
      "top1": 1.0
    }
  },
  "dp_final": {
    "chosen_index": 0,
    "chosen_term": "Bactériurie significative à Escherichia coli",
    "chosen_code": "N39.0",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 1.0 — source: llm_das"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Bactériurie significative à Escherichia coli",
        "code": "N39.0",
        "source": "llm_das",
        "is_comorbidity_like": false,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 1,
        "num_occurrences": 1,
        "score": 1.0,
        "score_details": {
          "section": 1,
          "confidence": 0
        }
      }
    ],
    "debug_scores": {
      "top1": 1.0
    }
  },
  "quality_flags": {
    "rag_status": "error",
    "crh_only_mode": true
  },
  "diagnostics_associes": [],
  "actes_ccam": [],
  "antecedents": [],
  "traitements_sortie": [],
  "biologie_cle": [
    {
      "test": "Leucocytes",
      "valeur": "5",
      "valeur_num": 5.0,
      "anomalie": false,
      "quality": "ok",
      "source_page": 1,
      "source_excerpt": "...ie ci-dessous rendu(s) sous accréditation (1) sauf mention contraire\nECBU - Milieu de jet\nCytologie\nLeucocytes 5 /µL <10\nAutomate Iris IQ 200 Select (Beckman-Coulter)\nHématies 3 /µL <10\nAutomate Iris IQ 200 Sel..."
    }
  ],
  "biologie_discarded": [],
  "imagerie": [],
  "complications": [],
  "alertes_codage": [
    "QUALITE DEGRADEE : erreur RAG — codage sans référentiels",
    "CMA niveau 2 : 'Bactériurie significative à Escherichia coli' (N39.0) — sévérité non_evalue",
    "QC: Le dossier clinique est très limité. L'absence d'informations cliniques supplémentaires rend difficile la validation précise du codage.  Il est impératif d'obtenir plus de détails sur les symptômes du patient, ses antécédents et l'examen clinique.",
    "QC: La justification fournie pour le code N39.0 est insuffisante et potentiellement contradictoire avec les données disponibles (absence de leucocyturie).",
    "QC: L'absence de preuves cliniques documentées pour justifier le code N39.0 est préoccupante.  Il est essentiel de documenter les raisons cliniques qui motivent l'attribution de ce code.",
    "RULE-DAS-TO-DP: DP absent → DAS N39.0 (Bactériurie significative à Escherichia coli) promu en DP",
    "DECISIONS[PDF]: 1 ligne(s)",
    "DECISION: diagnostic_principal N39.0 promu en DP (RULE-DAS-TO-DP)",
    "VETOS[PDF]: NEED_INFO (score=85)",
    "VETO-02 [MEDIUM] diagnostics_associes[0]: DAS N39.0 sans preuve exploitable"
  ],
  "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": "NEED_INFO",
    "score_contestabilite": 85,
    "issues": [
      {
        "veto": "VETO-02",
        "severity": "MEDIUM",
        "where": "diagnostics_associes[0]",
        "message": "DAS N39.0 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": "N39.0",
        "libelle": "Bactériurie significative à Escherichia coli",
        "type_diag": "DP",
        "items": [
          {
            "categorie": "biologie",
            "element": "ECBU",
            "statut": "absent",
            "importance": "obligatoire",
            "impact_cpam": "ECBU obligatoire pour documenter une infection urinaire"
          }
        ],
        "score": 30,
        "verdict": "indefendable",
        "resume": "0/1 obligatoires"
      }
    ],
    "score_global": 30,
    "verdict_global": "indefendable",
    "documents_presents": [
      "crh"
    ],
    "documents_manquants": []
  },
  "processing_time_s": 136.28,
  "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": []
  }
}