2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

1.22.4.1.33 v3 Code System DocumentCompletion

This code system (http://hl7.org/fhir/v3/DocumentCompletion) is defined as part of HL7 v3.

Formal value Set definition (identifier http://hl7.org/fhir/v3/vs/DocumentCompletion): XML or JSON

Release Date: 2014-12-11

OID for code system: 2.16.840.1.113883.5.33

OID for value set: 2.16.840.1.113883.1.11.271 (this is the value set that includes the entire code system)

1.22.4.1.33.1 Description

Identifies the current completion state of a clinical document.

LevelCodeDisplayDefinition
1AU authenticated A completion status in which a document has been signed manually or electronically by one or more individuals who attest to its accuracy. No explicit determination is made that the assigned individual has performed the authentication. While the standard allows multiple instances of authentication, it would be typical to have a single instance of authentication, usually by the assigned individual.
1DI dictated A completion status in which information has been orally recorded but not yet transcribed.
1DO documented A completion status in which document content, other than dictation, has been received but has not been translated into the final electronic format. Examples include paper documents, whether hand-written or typewritten, and intermediate electronic forms, such as voice to text.
1IN incomplete A completion status in which information is known to be missing from a transcribed document.
1IP in progress A workflow status where the material has been assigned to personnel to perform the task of transcription. The document remains in this state until the document is transcribed.
1LA legally authenticated A completion status in which a document has been signed manually or electronically by the individual who is legally responsible for that document. This is the most mature state in the workflow progression.
1NU nullified document A completion status in which a document was created in error or was placed in the wrong chart. The document is no longer available.
1PA pre-authenticated A completion status in which a document is transcribed but not authenticated.
1UC unsigned completed document A completion status where the document is complete and there is no expectation that the document will be signed.