13fe9fa666
Résultats de re-traitement pipeline v2 sur 261 dossiers. Co-Authored-By: Claude Opus 4.6 <noreply@anthropic.com>
126 lines
4.2 KiB
JSON
126 lines
4.2 KiB
JSON
{
|
|
"source_file": "trackare-BA060655-23127321_BA060655_23127321.pdf",
|
|
"document_type": "trackare",
|
|
"sejour": {
|
|
"sexe": "M",
|
|
"age": 29,
|
|
"date_entree": "01/07/2023",
|
|
"date_sortie": "06/07/2023",
|
|
"duree_sejour": 5,
|
|
"mode_entree": "Autres admissions urgentes",
|
|
"poids": 76.0,
|
|
"taille": 180.0
|
|
},
|
|
"diagnostic_principal": {
|
|
"texte": "Infection post-opératoire de la fracture du cubitus",
|
|
"cim10_suggestion": "T81.4",
|
|
"cim10_confidence": "medium",
|
|
"cim10_final": "T81.4",
|
|
"cim10_decision": {
|
|
"action": "PROMOTE_DP",
|
|
"final_code": "T81.4",
|
|
"reason": "DAS promu en DP (score (2, 2, 4))",
|
|
"needs_info": [],
|
|
"applied_rules": [
|
|
"RULE-DAS-TO-DP"
|
|
]
|
|
},
|
|
"justification": "Le contexte clinique mentionne explicitement une complication 'Infection' survenant lors d'un séjour pour fracture du cubitus (S52.00). Une infection post-opératoire ou post-traumatique mobilise des ressources supplémentaires (antibiothérapie, surveillance, soins locaux) et constitue un DAS significatif distinct du diagnostic principal traumatique.",
|
|
"sources_rag": [],
|
|
"preuves_cliniques": [],
|
|
"source": "llm_das"
|
|
},
|
|
"dp_final": {
|
|
"verdict": "REVIEW",
|
|
"evidence": [],
|
|
"reason": "Aucun DP disponible",
|
|
"candidates": []
|
|
},
|
|
"quality_flags": {
|
|
"rag_status": "error",
|
|
"no_dp_source": true
|
|
},
|
|
"diagnostics_associes": [],
|
|
"actes_ccam": [],
|
|
"antecedents": [],
|
|
"traitements_sortie": [],
|
|
"biologie_cle": [],
|
|
"biologie_discarded": [],
|
|
"imagerie": [],
|
|
"complications": [
|
|
{
|
|
"texte": "Infection",
|
|
"source_page": 7,
|
|
"source_excerpt": "...ESHABILLAGE : AIDE - 3xJ [6h 12h 22h] 03/07/2023 Mélanie\nRéalisé\nCOMPLETE Normal 14:00 BESSONART\nDESINFECTION\n- 3xJ [6h 12h 22h] 03/07/2023 Mélanie\nENVIRONNEMENT Réalisé\nNormal 14:00 BESSONART\nPATIENT\n- 3xJ [6..."
|
|
}
|
|
],
|
|
"alertes_codage": [
|
|
"QUALITE DEGRADEE : erreur RAG — codage sans référentiels",
|
|
"CMA niveau 3 : 'Infection post-opératoire de la fracture du cubitus' (T81.4) — sévérité non_evalue",
|
|
"QC: Le dossier clinique est incomplet. Il manque la mention de la fracture du cubitus (S52.00) et des détails sur l'intervention chirurgicale (si elle a eu lieu).",
|
|
"QC: La nature exacte de l'infection (locale, généralisée, type d'agent pathogène) n'est pas précisée, ce qui limite la spécificité du codage.",
|
|
"QC: Il est crucial de déterminer si l'infection est une complication directe de la fracture ou de l'intervention chirurgicale pour justifier le code T81.4.",
|
|
"RULE-DAS-TO-DP: DP absent → DAS T81.4 (Infection post-opératoire de la fracture du cubitus) promu en DP",
|
|
"DECISIONS[PDF]: 1 ligne(s)",
|
|
"DECISION: diagnostic_principal T81.4 promu en DP (RULE-DAS-TO-DP)",
|
|
"VETOS[PDF]: NEED_INFO (score=85)",
|
|
"VETO-02 [MEDIUM] diagnostics_associes[0]: DAS T81.4 sans preuve exploitable",
|
|
"Aucun DP extrait (ni Trackare ni CRH)"
|
|
],
|
|
"source_files": [],
|
|
"ghm_estimation": {
|
|
"cmd": "21",
|
|
"cmd_libelle": "Traumatismes",
|
|
"type_ghm": "M",
|
|
"severite": 1,
|
|
"ghm_approx": "21M??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 T81.4 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": [],
|
|
"score_global": 100,
|
|
"verdict_global": "defendable",
|
|
"documents_presents": [
|
|
"trackare"
|
|
],
|
|
"documents_manquants": []
|
|
},
|
|
"processing_time_s": 491.55,
|
|
"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": []
|
|
}
|
|
} |