V3-DocumentCompletion.xml

Identifies the current completion state of a clinical document.

Raw XML

<ValueSet xmlns="http://hl7.org/fhir">
  <id value="v3-DocumentCompletion"/>
  <meta>
    <lastUpdated value="2015-07-31T00:00:00.000+10:00"/>
    <profile value="http://hl7.org/fhir/StructureDefinition/valueset-shareable-definition"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
      <p>Release Date: 2015-07-31</p>

      <p>OID for code system: 2.16.840.1.113883.5.33</p>

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

      <h2>Description</h2>

      <p>
                  Identifies the current completion state of a clinical document.
        <br/>

               
      </p>

      <hr/>

      <table class="grid">
 
        <tr>
          <td>
            <b>Level</b>
          </td>
          <td>
            <b>Code</b>
          </td>
          <td>
            <b>Display</b>
          </td>
          <td>
            <b>Definition</b>
          </td>
        </tr>
 
        <tr>
          <td>1</td>
          <td>AU
            <a name="AU"> </a>
          </td>
          <td>authenticated</td>
          <td>
                        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.
            <br/>

                     
          </td>
        </tr>
 
        <tr>
          <td>1</td>
          <td>DI
            <a name="DI"> </a>
          </td>
          <td>dictated</td>
          <td>
                        A completion status in which information has been orally recorded
               but not yet transcribed.
            <br/>

                     
          </td>
        </tr>
 
        <tr>
          <td>1</td>
          <td>DO
            <a name="DO"> </a>
          </td>
          <td>documented</td>
          <td>
                        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.
            <br/>

                     
          </td>
        </tr>
 
        <tr>
          <td>1</td>
          <td>IN
            <a name="IN"> </a>
          </td>
          <td>incomplete</td>
          <td>
                        A completion status in which information is known to be missing
               from a transcribed document.
            <br/>

                     
          </td>
        </tr>
 
        <tr>
          <td>1</td>
          <td>IP
            <a name="IP"> </a>
          </td>
          <td>in progress</td>
          <td>
                        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.
            <br/>

                     
          </td>
        </tr>
 
        <tr>
          <td>1</td>
          <td>LA
            <a name="LA"> </a>
          </td>
          <td>legally authenticated</td>
          <td>
                        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.
            <br/>

                     
          </td>
        </tr>
 
        <tr>
          <td>1</td>
          <td>NU
            <a name="NU"> </a>
          </td>
          <td>nullified document</td>
          <td>
                        A completion status in which a document was created in error or
               was placed in the wrong chart. The document is no longer available.
            <br/>

                     
          </td>
        </tr>
 
        <tr>
          <td>1</td>
          <td>PA
            <a name="PA"> </a>
          </td>
          <td>pre-authenticated</td>
          <td>
                        A completion status in which a document is transcribed but not
               authenticated.
            <br/>

                     
          </td>
        </tr>
 
        <tr>
          <td>1</td>
          <td>UC
            <a name="UC"> </a>
          </td>
          <td>unsigned completed document</td>
          <td>
                        A completion status where the document is complete and there is
               no expectation that the document will be signed.
            <br/>

                     
          </td>
        </tr>

      </table>

    </div>
  </text>
  <extension url="http://hl7.org/fhir/StructureDefinition/valueset-oid">
    <valueUri value="urn:oid:2.16.840.1.113883.1.11.271"/>
  </extension>
  <url value="http://hl7.org/fhir/ValueSet/v3-DocumentCompletion"/>
  <version value="2015-07-31"/>
  <name value="v3 Code System DocumentCompletion"/>
  <status value="active"/>
  <experimental value="false"/>
  <publisher value="HL7, Inc"/>
  <contact>
    <telecom>
      <system value="other"/>
      <value value="http://hl7.org"/>
    </telecom>
  </contact>
  <date value="2015-07-31"/>
  <description value=" Identifies the current completion state of a clinical document."/>
  <codeSystem>
    <extension url="http://hl7.org/fhir/StructureDefinition/valueset-oid">
      <valueUri value="urn:oid:2.16.840.1.113883.5.33"/>
    </extension>
    <system value="http://hl7.org/fhir/v3/DocumentCompletion"/>
    <caseSensitive value="true"/>
    <concept>
      <code value="AU"/>
      <abstract value="false"/>
      <display value="authenticated"/>
      <definition value="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."/>
    </concept>
    <concept>
      <code value="DI"/>
      <abstract value="false"/>
      <display value="dictated"/>
      <definition value="A completion status in which information has been orally recorded but not yet transcribed."/>
    </concept>
    <concept>
      <code value="DO"/>
      <abstract value="false"/>
      <display value="documented"/>
      <definition value="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."/>
    </concept>
    <concept>
      <code value="IN"/>
      <abstract value="false"/>
      <display value="incomplete"/>
      <definition value="A completion status in which information is known to be missing from a transcribed document."/>
    </concept>
    <concept>
      <code value="IP"/>
      <abstract value="false"/>
      <display value="in progress"/>
      <definition value="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."/>
    </concept>
    <concept>
      <code value="LA"/>
      <abstract value="false"/>
      <display value="legally authenticated"/>
      <definition value="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."/>
    </concept>
    <concept>
      <code value="NU"/>
      <abstract value="false"/>
      <display value="nullified document"/>
      <definition value="A completion status in which a document was created in error or was placed in the wrong
         chart. The document is no longer available."/>
    </concept>
    <concept>
      <code value="PA"/>
      <abstract value="false"/>
      <display value="pre-authenticated"/>
      <definition value="A completion status in which a document is transcribed but not authenticated."/>
    </concept>
    <concept>
      <code value="UC"/>
      <abstract value="false"/>
      <display value="unsigned completed document"/>
      <definition value="A completion status where the document is complete and there is no expectation that the
         document will be signed."/>
    </concept>
  </codeSystem>
</ValueSet>