Résultats de re-traitement pipeline v2 sur 261 dossiers. Co-Authored-By: Claude Opus 4.6 <noreply@anthropic.com>
749 lines
24 KiB
JSON
749 lines
24 KiB
JSON
{
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"source_file": "CRH 23075530.pdf",
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"document_type": "crh",
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"sejour": {
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"sexe": "F",
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"age": 51,
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"date_entree": "17/04/2023",
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"date_sortie": "21/04/2023",
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"duree_sejour": 4
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},
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"diagnostic_principal": {
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"texte": "Tabagisme",
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"cim10_suggestion": "F17.2",
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"cim10_confidence": "high",
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"cim10_final": "F17.2",
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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": "nuke3",
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"source_page": 1,
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"source_excerpt": "...nd@ch-cotebasque.fr\nAllergie : Métronidazole, œufs\nDr Mathieu AUZI\nDES Médecine Générale\nToxiques : Tabagisme actif estimé à 4PA.\nDIU Nutrition\nRPPS : 10100422012\nmauzi@ch-cotebasque.fr Traitements à l'entrée..."
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},
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"dp_selection": {
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"chosen_index": 2,
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"chosen_term": "Tabagisme",
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"chosen_code": "F17.2",
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"verdict": "CONFIRMED",
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"evidence": [
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"Score 5.0 — source: regex (section forte)",
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"Conclusion: «diabète de type 2 bien équilibré pendant l'hospitalisation, pas de modification de traitement\nmgschwind@ch-cotebasque.fr urticaire chronique\nDr Mathieu AUZI\nDES Médecine Générale\nDIU Nutrition\nRPPS : 10100422012\nmauzi@ch-cotebasque.fr\nDr Am»",
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"Delta +3.0 vs Diabète de type 2 (E11.9)"
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],
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"reason": "Écart score 3.0 >= seuil 3.0",
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"candidates": [
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{
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"index": 2,
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"term": "Tabagisme",
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"code": "F17.2",
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"source": "regex",
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|
"is_comorbidity_like": false,
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|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 3,
|
|
"num_occurrences": 1,
|
|
"score": 5.0,
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|
"score_details": {
|
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"section": 3,
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"confidence": 0,
|
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"diag_section_bonus": 2
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}
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},
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{
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"index": 1,
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"term": "Diabète de type 2",
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"code": "E11.9",
|
|
"source": "regex",
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"is_comorbidity_like": true,
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|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 3,
|
|
"num_occurrences": 1,
|
|
"score": 2.0,
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"score_details": {
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"section": 3,
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"confidence": 0,
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|
"diag_section_bonus": 2,
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"comorbidity_malus": -3
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}
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},
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{
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"index": 3,
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"term": "Hypothyroïdie",
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"code": "E03.9",
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"source": "llm_das",
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"is_comorbidity_like": false,
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|
"is_symptom_like": false,
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|
"is_act_only": false,
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|
"section_strength": 1,
|
|
"num_occurrences": 1,
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"score": 1.0,
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"score_details": {
|
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"section": 1,
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"confidence": 0
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}
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},
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{
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"index": 5,
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"term": "Infection urinaire",
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"code": "N39.0",
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"source": "llm_das",
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"is_comorbidity_like": false,
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|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 1,
|
|
"num_occurrences": 1,
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|
"score": 1.0,
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"score_details": {
|
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"section": 1,
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"confidence": 0
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}
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},
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{
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"index": 6,
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"term": "Thrombocytose",
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"code": "D47.3",
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"source": "llm_das",
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"is_comorbidity_like": false,
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"is_symptom_like": false,
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"is_act_only": false,
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"section_strength": 1,
|
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"num_occurrences": 1,
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"score": 1.0,
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"score_details": {
|
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"section": 1,
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"confidence": 0
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}
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},
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{
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"index": 0,
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"term": "Hypertension artérielle",
|
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"code": "I10",
|
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"source": "regex",
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"is_comorbidity_like": true,
|
|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 3,
|
|
"num_occurrences": 1,
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|
"score": 0.0,
|
|
"score_details": {
|
|
"section": 3,
|
|
"confidence": 0,
|
|
"comorbidity_malus": -3
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}
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},
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{
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"index": 4,
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|
"term": "Trouble dépressif caractérisé",
|
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"code": "F32.9",
|
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"source": "llm_das",
|
|
"is_comorbidity_like": true,
|
|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 1,
|
|
"num_occurrences": 1,
|
|
"score": -2.0,
|
|
"score_details": {
|
|
"section": 1,
|
|
"confidence": 0,
|
|
"comorbidity_malus": -3
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}
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}
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],
|
|
"debug_scores": {
|
|
"top1": 5.0,
|
|
"top2": 2.0,
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"delta": 3.0
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}
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},
|
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"dp_crh_only": {
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"chosen_index": 2,
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"chosen_term": "Tabagisme",
|
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"chosen_code": "F17.2",
|
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"verdict": "CONFIRMED",
|
|
"evidence": [
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|
"Score 5.0 — source: regex (section forte)",
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|
"Conclusion: «diabète de type 2 bien équilibré pendant l'hospitalisation, pas de modification de traitement\nmgschwind@ch-cotebasque.fr urticaire chronique\nDr Mathieu AUZI\nDES Médecine Générale\nDIU Nutrition\nRPPS : 10100422012\nmauzi@ch-cotebasque.fr\nDr Am»",
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|
"Delta +3.0 vs Diabète de type 2 (E11.9)"
|
|
],
|
|
"reason": "Écart score 3.0 >= seuil 3.0",
|
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"candidates": [
|
|
{
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|
"index": 2,
|
|
"term": "Tabagisme",
|
|
"code": "F17.2",
|
|
"source": "regex",
|
|
"is_comorbidity_like": false,
|
|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 3,
|
|
"num_occurrences": 1,
|
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"score": 5.0,
|
|
"score_details": {
|
|
"section": 3,
|
|
"confidence": 0,
|
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"diag_section_bonus": 2
|
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}
|
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},
|
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{
|
|
"index": 1,
|
|
"term": "Diabète de type 2",
|
|
"code": "E11.9",
|
|
"source": "regex",
|
|
"is_comorbidity_like": true,
|
|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 3,
|
|
"num_occurrences": 1,
|
|
"score": 2.0,
|
|
"score_details": {
|
|
"section": 3,
|
|
"confidence": 0,
|
|
"diag_section_bonus": 2,
|
|
"comorbidity_malus": -3
|
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}
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},
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{
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"index": 3,
|
|
"term": "Hypothyroïdie",
|
|
"code": "E03.9",
|
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"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": {
|
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"section": 1,
|
|
"confidence": 0
|
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}
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},
|
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{
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"index": 5,
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"term": "Infection urinaire",
|
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"code": "N39.0",
|
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"source": "llm_das",
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|
"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
|
|
}
|
|
},
|
|
{
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|
"index": 6,
|
|
"term": "Thrombocytose",
|
|
"code": "D47.3",
|
|
"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
|
|
}
|
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},
|
|
{
|
|
"index": 0,
|
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"term": "Hypertension artérielle",
|
|
"code": "I10",
|
|
"source": "regex",
|
|
"is_comorbidity_like": true,
|
|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 3,
|
|
"num_occurrences": 1,
|
|
"score": 0.0,
|
|
"score_details": {
|
|
"section": 3,
|
|
"confidence": 0,
|
|
"comorbidity_malus": -3
|
|
}
|
|
},
|
|
{
|
|
"index": 4,
|
|
"term": "Trouble dépressif caractérisé",
|
|
"code": "F32.9",
|
|
"source": "llm_das",
|
|
"is_comorbidity_like": true,
|
|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 1,
|
|
"num_occurrences": 1,
|
|
"score": -2.0,
|
|
"score_details": {
|
|
"section": 1,
|
|
"confidence": 0,
|
|
"comorbidity_malus": -3
|
|
}
|
|
}
|
|
],
|
|
"debug_scores": {
|
|
"top1": 5.0,
|
|
"top2": 2.0,
|
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"delta": 3.0
|
|
}
|
|
},
|
|
"dp_final": {
|
|
"chosen_index": 2,
|
|
"chosen_term": "Tabagisme",
|
|
"chosen_code": "F17.2",
|
|
"verdict": "CONFIRMED",
|
|
"evidence": [
|
|
"Score 5.0 — source: regex (section forte)",
|
|
"Conclusion: «diabète de type 2 bien équilibré pendant l'hospitalisation, pas de modification de traitement\nmgschwind@ch-cotebasque.fr urticaire chronique\nDr Mathieu AUZI\nDES Médecine Générale\nDIU Nutrition\nRPPS : 10100422012\nmauzi@ch-cotebasque.fr\nDr Am»",
|
|
"Delta +3.0 vs Diabète de type 2 (E11.9)"
|
|
],
|
|
"reason": "Écart score 3.0 >= seuil 3.0",
|
|
"candidates": [
|
|
{
|
|
"index": 2,
|
|
"term": "Tabagisme",
|
|
"code": "F17.2",
|
|
"source": "regex",
|
|
"is_comorbidity_like": false,
|
|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 3,
|
|
"num_occurrences": 1,
|
|
"score": 5.0,
|
|
"score_details": {
|
|
"section": 3,
|
|
"confidence": 0,
|
|
"diag_section_bonus": 2
|
|
}
|
|
},
|
|
{
|
|
"index": 1,
|
|
"term": "Diabète de type 2",
|
|
"code": "E11.9",
|
|
"source": "regex",
|
|
"is_comorbidity_like": true,
|
|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 3,
|
|
"num_occurrences": 1,
|
|
"score": 2.0,
|
|
"score_details": {
|
|
"section": 3,
|
|
"confidence": 0,
|
|
"diag_section_bonus": 2,
|
|
"comorbidity_malus": -3
|
|
}
|
|
},
|
|
{
|
|
"index": 3,
|
|
"term": "Hypothyroïdie",
|
|
"code": "E03.9",
|
|
"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
|
|
}
|
|
},
|
|
{
|
|
"index": 5,
|
|
"term": "Infection urinaire",
|
|
"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
|
|
}
|
|
},
|
|
{
|
|
"index": 6,
|
|
"term": "Thrombocytose",
|
|
"code": "D47.3",
|
|
"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
|
|
}
|
|
},
|
|
{
|
|
"index": 0,
|
|
"term": "Hypertension artérielle",
|
|
"code": "I10",
|
|
"source": "regex",
|
|
"is_comorbidity_like": true,
|
|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 3,
|
|
"num_occurrences": 1,
|
|
"score": 0.0,
|
|
"score_details": {
|
|
"section": 3,
|
|
"confidence": 0,
|
|
"comorbidity_malus": -3
|
|
}
|
|
},
|
|
{
|
|
"index": 4,
|
|
"term": "Trouble dépressif caractérisé",
|
|
"code": "F32.9",
|
|
"source": "llm_das",
|
|
"is_comorbidity_like": true,
|
|
"is_symptom_like": false,
|
|
"is_act_only": false,
|
|
"section_strength": 1,
|
|
"num_occurrences": 1,
|
|
"score": -2.0,
|
|
"score_details": {
|
|
"section": 1,
|
|
"confidence": 0,
|
|
"comorbidity_malus": -3
|
|
}
|
|
}
|
|
],
|
|
"debug_scores": {
|
|
"top1": 5.0,
|
|
"top2": 2.0,
|
|
"delta": 3.0
|
|
}
|
|
},
|
|
"quality_flags": {
|
|
"rag_status": "error",
|
|
"crh_only_mode": true
|
|
},
|
|
"diagnostics_associes": [
|
|
{
|
|
"texte": "Hypertension artérielle",
|
|
"cim10_suggestion": "I10",
|
|
"cim10_confidence": "high",
|
|
"cim10_final": "I10",
|
|
"sources_rag": [],
|
|
"preuves_cliniques": [],
|
|
"niveau_severite": "non_evalue",
|
|
"niveau_cma": 1,
|
|
"source": "regex"
|
|
},
|
|
{
|
|
"texte": "Diabète de type 2",
|
|
"cim10_suggestion": "E11.9",
|
|
"cim10_confidence": "high",
|
|
"cim10_final": "E11.9",
|
|
"sources_rag": [],
|
|
"preuves_cliniques": [],
|
|
"est_cma": true,
|
|
"niveau_severite": "non_evalue",
|
|
"niveau_cma": 2,
|
|
"source": "regex",
|
|
"source_page": 1,
|
|
"source_excerpt": "...DESC Nutrition\nAncien Chef de Clinique CHU Personnels :\nTours - Hypopthyroïdie\nRPPS : 10002083912\n- Diabète de type 2 connu depuis 6 ans\nlritz@ch-cotebasque.fr\n- Infections urinaires\nDr Elisa MAURY - HTA\nDES Endocrino..."
|
|
},
|
|
{
|
|
"texte": "Hypothyroïdie",
|
|
"cim10_suggestion": "E03.9",
|
|
"cim10_confidence": "high",
|
|
"cim10_final": "E03.9",
|
|
"justification": "Antécédent actif mentionné dans les ATCD avec traitement par lévothyroxine 50mg à l'entrée. Pathologie chronique pertinente pour le séjour d'un patient diabétique déséquilibré, mobilisant des ressources de suivi.",
|
|
"sources_rag": [],
|
|
"preuves_cliniques": [],
|
|
"niveau_severite": "non_evalue",
|
|
"niveau_cma": 1,
|
|
"source": "llm_das"
|
|
},
|
|
{
|
|
"texte": "Trouble dépressif caractérisé",
|
|
"cim10_suggestion": "F32.9",
|
|
"cim10_confidence": "medium",
|
|
"cim10_final": "F32.9",
|
|
"justification": "Episodes dépressifs caractérisés avec hospitalisations psychiatriques antérieures mentionnés explicitement. Traitement par vortioxétine 10mg à l'entrée. Pertinent car contribue aux difficultés de prise en charge à domicile (thymie basse) et mobilise des ressources de suivi psychologique.",
|
|
"sources_rag": [],
|
|
"preuves_cliniques": [],
|
|
"niveau_severite": "non_evalue",
|
|
"niveau_cma": 1,
|
|
"source": "llm_das"
|
|
},
|
|
{
|
|
"texte": "Infection urinaire",
|
|
"cim10_suggestion": "N39.0",
|
|
"cim10_confidence": "low",
|
|
"cim10_final": "N39.0",
|
|
"justification": "Antécédent d'infections urinaires récurrentes mentionné dans les ATCD. Contexte clinique indique 'Complications : Infection' sans autre précision. Pertinent pour un patient diabétique avec antécédent d'infections urinaires.",
|
|
"sources_rag": [],
|
|
"preuves_cliniques": [],
|
|
"est_cma": true,
|
|
"niveau_severite": "non_evalue",
|
|
"niveau_cma": 2,
|
|
"source": "llm_das"
|
|
},
|
|
{
|
|
"texte": "Thrombocytose",
|
|
"cim10_suggestion": "D47.3",
|
|
"cim10_confidence": "low",
|
|
"cim10_final": "D47.3",
|
|
"justification": "Plaquettes 424 [N: 150-400] (↑) - valeur élevée. Peut être réactionnelle à l'infection mentionnée, mais représente une anomalie biologique significative mobilisant des ressources.",
|
|
"sources_rag": [],
|
|
"preuves_cliniques": [],
|
|
"niveau_severite": "non_evalue",
|
|
"niveau_cma": 1,
|
|
"source": "llm_das"
|
|
}
|
|
],
|
|
"actes_ccam": [],
|
|
"antecedents": [],
|
|
"traitements_sortie": [],
|
|
"biologie_cle": [
|
|
{
|
|
"test": "ASAT",
|
|
"valeur": "29",
|
|
"valeur_num": 29.0,
|
|
"anomalie": false,
|
|
"quality": "ok",
|
|
"source_page": 2,
|
|
"source_excerpt": "...inologie et Mal. Hb 14.2g/dL, Hématies 5.08t/L, Leucocytes 14.57G/L, Plaquettes 424G/L\nMétaboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrition\nAncien Chef de Clinique CHU Créatinine 50µ..."
|
|
},
|
|
{
|
|
"test": "ALAT",
|
|
"valeur": "29",
|
|
"valeur_num": 29.0,
|
|
"anomalie": false,
|
|
"quality": "ok",
|
|
"source_page": 2,
|
|
"source_excerpt": "...Mal. Hb 14.2g/dL, Hématies 5.08t/L, Leucocytes 14.57G/L, Plaquettes 424G/L\nMétaboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrition\nAncien Chef de Clinique CHU Créatinine 50µmol/L, DFG 1..."
|
|
},
|
|
{
|
|
"test": "GGT",
|
|
"valeur": "107",
|
|
"valeur_num": 107.0,
|
|
"anomalie": true,
|
|
"quality": "ok",
|
|
"source_page": 2,
|
|
"source_excerpt": "...g/dL, Hématies 5.08t/L, Leucocytes 14.57G/L, Plaquettes 424G/L\nMétaboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrition\nAncien Chef de Clinique CHU Créatinine 50µmol/L, DFG 108mL/min\nAn..."
|
|
},
|
|
{
|
|
"test": "PAL",
|
|
"valeur": "96",
|
|
"valeur_num": 96.0,
|
|
"anomalie": false,
|
|
"quality": "ok",
|
|
"source_page": 2,
|
|
"source_excerpt": "...es 5.08t/L, Leucocytes 14.57G/L, Plaquettes 424G/L\nMétaboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrition\nAncien Chef de Clinique CHU Créatinine 50µmol/L, DFG 108mL/min\nAngers HBA1c 1..."
|
|
},
|
|
{
|
|
"test": "Potassium",
|
|
"valeur": "4.5",
|
|
"valeur_num": 4.5,
|
|
"anomalie": false,
|
|
"quality": "ok"
|
|
},
|
|
{
|
|
"test": "Hémoglobine",
|
|
"valeur": "14.2",
|
|
"valeur_num": 14.2,
|
|
"anomalie": false,
|
|
"quality": "ok"
|
|
},
|
|
{
|
|
"test": "Plaquettes",
|
|
"valeur": "424",
|
|
"valeur_num": 424.0,
|
|
"anomalie": true,
|
|
"quality": "ok",
|
|
"source_page": 2,
|
|
"source_excerpt": "...Biologie d'entrée :\nDES Endocrinologie et Mal. Hb 14.2g/dL, Hématies 5.08t/L, Leucocytes 14.57G/L, Plaquettes 424G/L\nMétaboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrition\nAncien Chef de Cl..."
|
|
},
|
|
{
|
|
"test": "Leucocytes",
|
|
"valeur": "14.57",
|
|
"valeur_num": 14.57,
|
|
"anomalie": true,
|
|
"quality": "ok",
|
|
"source_page": 2,
|
|
"source_excerpt": "...:\nDr Delphine DEMARSY Biologie d'entrée :\nDES Endocrinologie et Mal. Hb 14.2g/dL, Hématies 5.08t/L, Leucocytes 14.57G/L, Plaquettes 424G/L\nMétaboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrit..."
|
|
},
|
|
{
|
|
"test": "Créatinine",
|
|
"valeur": "50",
|
|
"valeur_num": 50.0,
|
|
"anomalie": false,
|
|
"quality": "ok",
|
|
"source_page": 2,
|
|
"source_excerpt": "...aboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrition\nAncien Chef de Clinique CHU Créatinine 50µmol/L, DFG 108mL/min\nAngers HBA1c 11.2%, K+ 4.5mmol/L\nRPPS : 10004401718 LDL 1.24g/L, HDL 0.42g/..."
|
|
}
|
|
],
|
|
"biologie_discarded": [],
|
|
"imagerie": [],
|
|
"complications": [
|
|
{
|
|
"texte": "Infection",
|
|
"source_page": 1,
|
|
"source_excerpt": "...- Hypopthyroïdie\nRPPS : 10002083912\n- Diabète de type 2 connu depuis 6 ans\nlritz@ch-cotebasque.fr\n- Infections urinaires\nDr Elisa MAURY - HTA\nDES Endocrinologie et Mal.\n- Notion de problème hépatique\nMétaboliq..."
|
|
}
|
|
],
|
|
"alertes_codage": [
|
|
"QUALITE DEGRADEE : erreur RAG — codage sans référentiels",
|
|
"2 CMA probables détectées — impact potentiel sur le niveau de sévérité GHM",
|
|
"CMA niveau 2 : 'Diabète de type 2' (E11.9) — sévérité non_evalue",
|
|
"CMA niveau 2 : 'Infection urinaire' (N39.0) — sévérité non_evalue",
|
|
"QC: DAS I10 (Hypertension artérielle) à reconsidérer — Aucune preuve clinique. Pas de mention de l'HTA dans les données fournies. Absence de traitement antihypertenseur documenté. Codage injustifié.",
|
|
"QC: DAS E11.9 (Diabète de type 2) à reconsidérer — Aucune preuve clinique. Pas de glycémie anormale, pas de mention du diabète dans les ATCD ou le traitement. Codage sans fondement.",
|
|
"QC: ⚠️ ALERTE CRITIQUE : 4 codes sur 7 sont codés SANS PREUVE DOCUMENTÉE dans le dossier (F17.2, I10, E11.9, N39.0). Cela constitue une violation majeure des règles PMSI.",
|
|
"QC: ⚠️ ALERTE : La complication 'Infection' est codée de manière spéculative en N39.0 (ITU) sans confirmation clinique. Demander la documentation précise du type et du site d'infection.",
|
|
"QC: ⚠️ ALERTE : D47.3 (thrombocytose essentielle) est un diagnostic hématologique grave, inapproprié pour une thrombocytose réactionnelle. À supprimer.",
|
|
"QC: ⚠️ ALERTE : F32.9 nécessite clarification : trouble dépressif actuel ou antécédent ? Distinction importante pour le codage.",
|
|
"QC: 📋 RECOMMANDATION : Demander au clinicien de compléter/clarifier le dossier avant validation finale. Codage actuel non conforme aux standards PMSI (absence de justification documentée).",
|
|
"VETOS[PDF]: NEED_INFO (score=25)",
|
|
"VETO-02 [MEDIUM] diagnostics_associes[0]: DAS I10 sans preuve exploitable",
|
|
"VETO-02 [MEDIUM] diagnostics_associes[2]: DAS E03.9 sans preuve exploitable",
|
|
"VETO-02 [MEDIUM] diagnostics_associes[3]: DAS F32.9 sans preuve exploitable",
|
|
"VETO-02 [MEDIUM] diagnostics_associes[4]: DAS N39.0 sans preuve exploitable",
|
|
"VETO-02 [MEDIUM] diagnostics_associes[5]: DAS D47.3 sans preuve exploitable"
|
|
],
|
|
"source_files": [],
|
|
"ghm_estimation": {
|
|
"cmd": "20",
|
|
"cmd_libelle": "Troubles mentaux liés à l'alcool et aux toxiques",
|
|
"type_ghm": "M",
|
|
"severite": 2,
|
|
"ghm_approx": "20M??2",
|
|
"cma_count": 2,
|
|
"cms_count": 0,
|
|
"alertes": []
|
|
},
|
|
"controles_cpam": [],
|
|
"veto_report": {
|
|
"verdict": "NEED_INFO",
|
|
"score_contestabilite": 25,
|
|
"issues": [
|
|
{
|
|
"veto": "VETO-02",
|
|
"severity": "MEDIUM",
|
|
"where": "diagnostics_associes[0]",
|
|
"message": "DAS I10 sans preuve exploitable",
|
|
"citation": "Principe de preuve : tout diagnostic/acte doit être étayé par une trace dans le dossier médical (Guide Méthodologique MCO)"
|
|
},
|
|
{
|
|
"veto": "VETO-02",
|
|
"severity": "MEDIUM",
|
|
"where": "diagnostics_associes[2]",
|
|
"message": "DAS E03.9 sans preuve exploitable",
|
|
"citation": "Principe de preuve : tout diagnostic/acte doit être étayé par une trace dans le dossier médical (Guide Méthodologique MCO)"
|
|
},
|
|
{
|
|
"veto": "VETO-02",
|
|
"severity": "MEDIUM",
|
|
"where": "diagnostics_associes[3]",
|
|
"message": "DAS F32.9 sans preuve exploitable",
|
|
"citation": "Principe de preuve : tout diagnostic/acte doit être étayé par une trace dans le dossier médical (Guide Méthodologique MCO)"
|
|
},
|
|
{
|
|
"veto": "VETO-02",
|
|
"severity": "MEDIUM",
|
|
"where": "diagnostics_associes[4]",
|
|
"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)"
|
|
},
|
|
{
|
|
"veto": "VETO-02",
|
|
"severity": "MEDIUM",
|
|
"where": "diagnostics_associes[5]",
|
|
"message": "DAS D47.3 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": "E11.9",
|
|
"libelle": "Diabète de type 2",
|
|
"type_diag": "DAS",
|
|
"items": [
|
|
{
|
|
"categorie": "biologie",
|
|
"element": "HbA1c",
|
|
"statut": "present",
|
|
"valeur": "14.2",
|
|
"importance": "recommande",
|
|
"impact_cpam": "HbA1c attendue pour documenter l'équilibre glycémique"
|
|
},
|
|
{
|
|
"categorie": "biologie",
|
|
"element": "Glycémie",
|
|
"statut": "absent",
|
|
"importance": "recommande",
|
|
"impact_cpam": "Glycémie de base pour confirmer le diagnostic"
|
|
}
|
|
],
|
|
"score": 85,
|
|
"verdict": "defendable",
|
|
"resume": "1/2 recommandés"
|
|
},
|
|
{
|
|
"code": "N39.0",
|
|
"libelle": "Infection urinaire",
|
|
"type_diag": "DAS",
|
|
"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": 57,
|
|
"verdict_global": "indefendable",
|
|
"documents_presents": [
|
|
"crh"
|
|
],
|
|
"documents_manquants": []
|
|
},
|
|
"processing_time_s": 20.65,
|
|
"metrics": {
|
|
"das_total": 6,
|
|
"das_active": 6,
|
|
"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": []
|
|
}
|
|
} |