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ScanOGC_extract/output/extraction_ogc_raw_mistral.json
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{
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"duree_rum_fin": "08/12/2016",
"nature_suppl": "0",
"nb_suppl": "0",
"duree_rum_calculee_j": 3
},
"rum_reco": {
"n_rum": "1/1",
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"duree_rum_fin": "08/12/2016",
"nature_suppl": "0",
"nb_suppl": "0",
"duree_rum_calculee_j": 3
},
"dp_etab": {
"code": "M7116",
"libelle": "BURSITES INFECT., NCA - JAMBE"
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"dr_etab": {
"code": "",
"libelle": ""
},
"das_etab": [
{
"code": "L024",
"rang": "3",
"libelle": "ABCES CUTANE, FURONCLE ET ANTHRAX D'UN MB."
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],
"actes_etab": [
{
"code": "NJFA008",
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"libelle": "EXERESE 1HYGROMA GENOU AB. DIRECT"
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{
"code": "NJFA008",
"niveau": "4",
"libelle": "EXERESE 1HYGROMA GENOU AB. DIRECT"
}
],
"dp_reco": {
"code": "M7106"
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"code": ""
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"das_reco": [
{
"code": "M7106",
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}
],
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{
"code": "NJFA008",
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},
{
"code": "NJFA008",
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],
"ghm_etab": "08C422",
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"fsd": "",
"accord_desaccord": "Désaccord",
"nom_praticien_conseil": "DR JP VIGNAU"
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},
{
"page": 4,
"type": "ELEMENTS_PREUVE",
"data": {
"date": "03-02-2017",
"medecin_controleur_signataire": [
"Dr PROMAX"
],
"medecin_dim_signataire": "Dr ETTORCHI-TARDY",
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"photocopie": "",
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"date_obtention": ""
},
"compte_rendu_operatoire": {
"present": "oui",
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"date_obtention": ""
},
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"date_obtention": ""
},
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},
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},
"compte_rendu_anatomopathologie": {
"present": "non",
"photocopie": "",
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},
"observations_medicales": {
"present": "non",
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},
"dossier_transfusion": {
"present": "non",
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},
"dossier_anesthesie": {
"present": "non",
"photocopie": "",
"absent_date_1ere_demande": "",
"date_obtention": ""
},
"administration_therapeutique": {
"present": "oui",
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"absent_date_1ere_demande": "",
"date_obtention": ""
},
"compte_rendu_hospitalisation": {
"present": "oui",
"photocopie": "1",
"absent_date_1ere_demande": "",
"date_obtention": ""
},
"lettre_sortie": {
"present": "non",
"photocopie": "",
"absent_date_1ere_demande": "",
"date_obtention": ""
},
"surveillance_dossier_infirmier": {
"present": "non",
"photocopie": "",
"absent_date_1ere_demande": "1",
"date_obtention": ""
},
"prise_en_charge_psychologue": {
"present": "non",
"photocopie": "",
"absent_date_1ere_demande": "",
"date_obtention": ""
},
"prise_en_charge_kinesitherapeute": {
"present": "non",
"photocopie": "",
"absent_date_1ere_demande": "",
"date_obtention": ""
},
"prise_en_charge_dietetique": {
"present": "non",
"photocopie": "",
"absent_date_1ere_demande": "",
"date_obtention": ""
},
"autre": {
"present": "non",
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"date_obtention": ""
}
}
}
},
{
"page": 5,
"type": "FICHE_ADMIN_1_2",
"data": {
"n_ogc": "429",
"date_concertation": "17.03.18",
"argumentaire_medecin_controleur": " 109 : La facturation du GHS par l’établissement n’est pas conforme à l’article 1 de l’arrêté du 19 février 2015 modifié du fait d’un non-respect des règles de codage édictées dans l’annexe II de l’arrêté du 21 décembre 2015 modifiant l’arrêté du 22 février 2008. Le non-respect des règles porte sur le diagnostic principal (DP) codé par l’établissement dans le résumé d’unité médicale (RUM). Le DP n’est pas conforme aux règles de codage des diagnostics rappelées par l’annexe II, chapitre V, paragraphe 1 : « les diagnostics doivent figurer dans le RUM sous forme codée selon la plus récente mise à jour de la 10e révision de la Classification internationale des maladies (CIM-10) de l’Organisation mondiale de la santé et selon les extensions nationales données dans la plus récente version du Manuel des groupes homogènes de malades. (...) Le meilleur code est le plus précis par rapport à l’information à coder. » Au vu des éléments présents dans le dossier du patient, le code CIM-10 choisi pour le DP par l’établissement n’est pas le plus précis par rapport à l’information à coder."
}
},
{
"page": 6,
"type": "FICHE_ADMIN_2_2",
"data": {
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"maintien_avis_controleur": "oui",
"retour_groupage_dim": "",
"autre_groupage": "",
"avis_dim_final": "Désaccord",
"date_concertation": "17.3.19",
"nom_medecin_responsable_controle": "DR JP VIGNAU",
"nom_medecin_dim": "DR ETTORCHI-TARDY"
}
}
],
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]
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