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DocumentCompletion     

Identifies the current completion state of a clinical document.

Lvl Type, Domain name and/or Mnemonic code Concept ID Mnemonic Print Name Definition/Description
1 L:  (AU) 10581 AU 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.

1 L:  (DI) 10576 DI dictated

A completion status in which information has been orally recorded but not yet transcribed.

1 L:  (DO) 10577 DO 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.

1 L:  (IN) 10579 IN incomplete

A completion status in which information is known to be missing from a transcribed document.

1 L:  (IP) 10578 IP 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.

1 L:  (LA) 10582 LA 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.

1 L:  (PA) 10580 PA pre-authenticated

A completion status in which a document is transcribed but not authenticated.


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