t2a_v2/output/structured/148_23018396/CRH_23018396_cim10.json

{
  "source_file": "CRH 23018396.pdf",
  "document_type": "crh",
  "sejour": {
    "sexe": "F"
  },
  "diagnostic_principal": {
    "texte": "Sepsis",
    "cim10_suggestion": "A41.9",
    "cim10_confidence": "high",
    "cim10_final": "A41.9",
    "cim10_decision": {
      "action": "PROMOTE_DP",
      "final_code": "A41.9",
      "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": "...ATION\nGHRISSI Rabha _ 15/12/1947\nREPRISE D’ARTHROPLASTIE POUR INSTABILITE RESIDUELLE AVEC NOTION DE SEPSIS NON AVERE DANS\nPATIENTE OPEREE A L’HOPITAL DE LA TRINITE EN MARTINIQUE D’UNE PROTHESE TOTALE DE HAN..."
  },
  "dp_selection": {
    "chosen_index": 0,
    "chosen_term": "Sepsis",
    "chosen_code": "A41.9",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 3.0 — source: regex (section forte)"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Sepsis",
        "code": "A41.9",
        "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": "Sepsis",
    "chosen_code": "A41.9",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 3.0 — source: regex (section forte)"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Sepsis",
        "code": "A41.9",
        "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": "Sepsis",
    "chosen_code": "A41.9",
    "verdict": "CONFIRMED",
    "evidence": [
      "Score 3.0 — source: regex (section forte)"
    ],
    "reason": "Candidat unique",
    "candidates": [
      {
        "index": 0,
        "term": "Sepsis",
        "code": "A41.9",
        "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": [],
  "antecedents": [],
  "traitements_sortie": [],
  "biologie_cle": [],
  "biologie_discarded": [],
  "imagerie": [],
  "complications": [],
  "alertes_codage": [
    "QUALITE DEGRADEE : erreur RAG — codage sans référentiels",
    "CMA niveau 3 : 'Sepsis' (A41.9) — sévérité non_evalue",
    "QC: DAS A41.9 (Sepsis) à reconsidérer — ABSENCE TOTALE DE PREUVE CLINIQUE. Le codage indique explicitement 'Preuves: aucune'. Un diagnostic de sepsis ne peut être codé sans documentation clinique minimale (signes SIRS, culture positive, contexte infectieux, ou au minimum mention explicite du diagnostic dans le dossier). Ceci constitue un codage non justifié.",
    "QC: ⚠️ ANOMALIE CRITIQUE : Codage sans justification médicale - Violation de la règle fondamentale du PMSI",
    "QC: ⚠️ RISQUE DE FRAUDE PMSI : Codage d'un diagnostic grave sans preuve documentée",
    "QC: ⚠️ IMPACT FINANCIER : A41.9 génère une surpondération injustifiée du GHM",
    "QC: ⚠️ RECOMMANDATION : Demander au clinicien de clarifier : le sepsis est-il réellement présent ? Si oui, fournir les preuves (hémocultures, critères SIRS, etc.). Si non, supprimer le code.",
    "QC: ℹ️ Si infection documentée mais sans sepsis confirmé : utiliser un code plus spécifique (ex: A40.x, B95-B97 selon le germe)",
    "RULE-DAS-TO-DP: DP absent → DAS A41.9 (Sepsis) promu en DP",
    "DECISIONS[PDF]: 1 ligne(s)",
    "DECISION: diagnostic_principal A41.9 promu en DP (RULE-DAS-TO-DP)"
  ],
  "source_files": [],
  "ghm_estimation": {
    "cmd": "18",
    "cmd_libelle": "Maladies infectieuses et parasitaires",
    "type_ghm": "M",
    "severite": 1,
    "ghm_approx": "18M??1",
    "cma_count": 0,
    "cms_count": 0,
    "alertes": []
  },
  "controles_cpam": [],
  "veto_report": {
    "verdict": "PASS",
    "score_contestabilite": 95,
    "issues": [
      {
        "veto": "VETO-03",
        "severity": "LOW",
        "where": "diagnostics_associes[0]",
        "message": "DAS A41.9 potentiellement conditionnel",
        "citation": "Guide Méthodologique MCO : Un diagnostic conditionnel (suspecté, à éliminer) ne doit pas être codé comme confirmé"
      }
    ]
  },
  "completude": {
    "checks": [
      {
        "code": "A41.9",
        "libelle": "Sepsis",
        "type_diag": "DP",
        "items": [
          {
            "categorie": "biologie",
            "element": "CRP",
            "statut": "absent",
            "importance": "obligatoire",
            "impact_cpam": "Marqueur inflammatoire essentiel pour documenter un sepsis"
          },
          {
            "categorie": "biologie",
            "element": "Leucocytes",
            "statut": "absent",
            "importance": "obligatoire",
            "impact_cpam": "Leucocytose ou leucopénie attendue dans le sepsis"
          },
          {
            "categorie": "biologie",
            "element": "Procalcitonine",
            "statut": "absent",
            "importance": "recommande",
            "impact_cpam": "Marqueur spécifique d'infection bactérienne, renforce la preuve"
          },
          {
            "categorie": "biologie",
            "element": "Hémocultures",
            "statut": "absent",
            "importance": "recommande",
            "impact_cpam": "Documentation bactériologique du sepsis"
          }
        ],
        "score": 0,
        "verdict": "indefendable",
        "resume": "0/2 obligatoires, 0/2 recommandés"
      }
    ],
    "score_global": 0,
    "verdict_global": "indefendable",
    "documents_presents": [
      "crh"
    ],
    "documents_manquants": []
  },
  "processing_time_s": 11.91,
  "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": []
  }
}