t2a_v2/output/structured/10_23079252/CRO-23079252_cim10.json

{
  "source_file": "CRO-23079252.pdf",
  "document_type": "crh",
  "sejour": {
    "sexe": "M"
  },
  "diagnostic_principal": {
    "texte": "Cholécystite aiguë",
    "cim10_suggestion": "K81.0",
    "cim10_confidence": "high",
    "cim10_final": "K81.0",
    "cim10_decision": {
      "action": "PROMOTE_DP",
      "final_code": "K81.0",
      "reason": "DAS promu en DP (score (2, 3, 4))",
      "needs_info": [],
      "applied_rules": [
        "RULE-DAS-TO-DP"
      ]
    },
    "sources_rag": [],
    "preuves_cliniques": [],
    "source": "regex",
    "source_page": 1,
    "source_excerpt": "...4600 ANGLET\nMonsieur BENOIT RAMEIX\nNé le 16/02/1975\nCHOLECYSTECTOMIE SOUS COELIOSCOPIE\nIndication :\nCholécystite aiguë\nCompte rendu opératoire du 22.04.2023 :\nOpérateur : Docteur R. GONTIER\nAnesthésiste(s) Docteur L. K..."
  },
  "dp_selection": {
    "chosen_index": 0,
    "chosen_term": "Cholécystite aiguë",
    "chosen_code": "K81.0",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 3.0 — source: regex (section forte)"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Cholécystite aiguë",
        "code": "K81.0",
        "source": "regex",
        "is_comorbidity_like": false,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 3.0,
        "score_details": {
          "section": 3,
          "confidence": 0
        }
      }
    ],
    "debug_scores": {
      "top1": 3.0
    }
  },
  "dp_crh_only": {
    "chosen_index": 0,
    "chosen_term": "Cholécystite aiguë",
    "chosen_code": "K81.0",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 3.0 — source: regex (section forte)"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Cholécystite aiguë",
        "code": "K81.0",
        "source": "regex",
        "is_comorbidity_like": false,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 3.0,
        "score_details": {
          "section": 3,
          "confidence": 0
        }
      }
    ],
    "debug_scores": {
      "top1": 3.0
    }
  },
  "dp_final": {
    "chosen_index": 0,
    "chosen_term": "Cholécystite aiguë",
    "chosen_code": "K81.0",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 3.0 — source: regex (section forte)"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Cholécystite aiguë",
        "code": "K81.0",
        "source": "regex",
        "is_comorbidity_like": false,
        "is_symptom_like": false,
        "is_act_only": false,
        "section_strength": 3,
        "num_occurrences": 1,
        "score": 3.0,
        "score_details": {
          "section": 3,
          "confidence": 0
        }
      }
    ],
    "debug_scores": {
      "top1": 3.0
    }
  },
  "quality_flags": {
    "rag_status": "error",
    "crh_only_mode": true
  },
  "diagnostics_associes": [],
  "actes_ccam": [
    {
      "texte": "Cholécystectomie",
      "code_ccam_suggestion": "HMFC004",
      "sources_rag": [],
      "validite": "valide",
      "alertes": [],
      "source_page": 1,
      "source_excerpt": "...ouver l’artèr\ncanal cystique.\nSection entre clips du canal cystique et de l’artère.\nPoursuite de la cholécystectomie rétrograde.\nElectrocoagulation du lit vésiculaire\nOn positionne la vésicule dans un sac d’extractio..."
    }
  ],
  "antecedents": [],
  "traitements_sortie": [],
  "biologie_cle": [],
  "biologie_discarded": [],
  "imagerie": [],
  "complications": [],
  "alertes_codage": [
    "QUALITE DEGRADEE : erreur RAG — codage sans référentiels",
    "CMA niveau 3 : 'Cholécystite aiguë' (K81.0) — sévérité severe, marqueurs : aigue",
    "QC: DAS K81.0 (Cholécystite aiguë) à reconsidérer — ABSENCE TOTALE DE JUSTIFICATION ET DE PREUVE CLINIQUE. Le codage indique explicitement 'Preuves: aucune'. Un diagnostic de cholécystite aiguë ne peut être codé sans éléments cliniques, biologiques ou d'imagerie documentés (symptômes, signes de Murphy, échographie, bilan inflammatoire, etc.). Ce code ne respecte pas les règles de codage PMSI.",
    "QC: ⚠️ CODAGE NON JUSTIFIÉ : Aucune preuve clinique fournie pour K81.0",
    "QC: ⚠️ RISQUE DE FRAUDE PMSI : Codage d'un diagnostic sans documentation médicale",
    "QC: ⚠️ DOSSIER INCOMPLET : Informations cliniques insuffisantes pour valider tout codage",
    "QC: ⚠️ RECOMMANDATION : Demander au clinicien de fournir les éléments justificatifs (anamnèse, examen clinique, résultats paracliniques) ou supprimer le code",
    "RULE-DAS-TO-DP: DP absent → DAS K81.0 (Cholécystite aiguë) promu en DP",
    "DECISIONS[PDF]: 1 ligne(s)",
    "DECISION: diagnostic_principal K81.0 promu en DP (RULE-DAS-TO-DP)"
  ],
  "source_files": [],
  "ghm_estimation": {
    "cmd": "07",
    "cmd_libelle": "Affections hépatobiliaires et pancréatiques",
    "type_ghm": "C",
    "severite": 1,
    "ghm_approx": "07C??1",
    "cma_count": 0,
    "cms_count": 0,
    "alertes": []
  },
  "controles_cpam": [],
  "veto_report": {
    "verdict": "PASS",
    "score_contestabilite": 100,
    "issues": []
  },
  "completude": {
    "checks": [
      {
        "code": "HMFC004",
        "libelle": "Acte chirurgical nécessitant un CRO",
        "type_diag": "Acte",
        "items": [
          {
            "categorie": "document",
            "element": "CRO",
            "statut": "absent",
            "importance": "obligatoire",
            "impact_cpam": "Compte-rendu opératoire obligatoire pour tout acte chirurgical"
          }
        ],
        "score": 30,
        "verdict": "indefendable",
        "resume": "0/1 obligatoires"
      }
    ],
    "score_global": 30,
    "verdict_global": "indefendable",
    "documents_presents": [
      "crh"
    ],
    "documents_manquants": [
      "CRO"
    ]
  },
  "processing_time_s": 5.3,
  "metrics": {
    "das_total": 0,
    "das_active": 0,
    "das_excluded": 0,
    "das_removed": 0,
    "das_ruled_out": 0,
    "das_no_code": 0,
    "actes_total": 1,
    "actes_with_code": 1,
    "dp_has_code": true
  },
  "rules_runtime": {
    "router_version": 1,
    "mode": "strict",
    "enabled_packs": [
      "decisions_core",
      "vetos_core"
    ],
    "always_on_rules": [],
    "triggers_fired": []
  }
}