Release 5 Preview #2

This page is part of the FHIR Specification (v4.4.0: R5 Preview #2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R4 R3 R2

V3-DocumentCompletion.xml

Vocabulary Work GroupMaturity Level: N/AStandards Status: Informative

Raw XML (canonical form + also see XML Format Specification)

Identifies the current completion state of a clinical document.

<?xml version="1.0" encoding="UTF-8"?>

<ValueSet xmlns="http://hl7.org/fhir">
  <id value="v3-DocumentCompletion"/> 
  <meta> 
    <lastUpdated value="2019-07-31T00:00:00.000+10:00"/> 
    <profile value="http://hl7.org/fhir/StructureDefinition/shareablevalueset"/> 
  </meta> 
  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">
      <p> Release Date: 2019-07-31</p> 

      <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="v3-DocumentCompletion-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="v3-DocumentCompletion-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="v3-DocumentCompletion-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="v3-DocumentCompletion-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="v3-DocumentCompletion-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="v3-DocumentCompletion-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="v3-DocumentCompletion-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="v3-DocumentCompletion-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="v3-DocumentCompletion-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/structuredefinition-standards-status">
    <valueCode value="external"/> 
  </extension> 
  <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm">
    <valueInteger value="0"/> 
  </extension> 
  <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
    <valueCode value="vocab"/> 
  </extension> 
  <url value="http://terminology.hl7.org/ValueSet/v3-DocumentCompletion"/> 
  <identifier> 
    <system value="urn:ietf:rfc:3986"/> 
    <value value="urn:oid:2.16.840.1.113883.1.11.271"/> 
  </identifier> 
  <version value="2019-07-31"/> 
  <name value="v3.DocumentCompletion"/> 
  <title value="v3 Code System DocumentCompletion"/> 
  <status value="active"/> 
  <experimental value="false"/> 
  <date value="2019-07-31"/> 
  <publisher value="HL7, Inc"/> 
  <contact> 
    <telecom> 
      <system value="url"/> 
      <value value="http://hl7.org"/> 
    </telecom> 
  </contact> 
  <description value=" Identifies the current completion state of a clinical document."/> 
  <immutable value="true"/> 
  <compose> 
    <include> 
      <system value="http://terminology.hl7.org/CodeSystem/v3-DocumentCompletion"/> 
    </include> 
  </compose> 
</ValueSet> 

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.