This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). 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
Vocabulary Work Group | Maturity Level: N/A | Ballot Status: Informative |
Identifies the current completion state of a clinical document.
<CodeSystem xmlns="http://hl7.org/fhir"> <id value="v3-DocumentCompletion"/> <meta> <lastUpdated value="2017-07-31T00:00:00.000+10:00"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p> Release Date: 2017-07-31</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-ballot-status"> <valueString value="External"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm"> <valueInteger value="0"/> </extension> <url value="http://hl7.org/fhir/v3/DocumentCompletion"/> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:oid:2.16.840.1.113883.5.33"/> </identifier> <version value="2017-07-31"/> <name value="v3 Code System DocumentCompletion"/> <status value="active"/> <experimental value="false"/> <date value="2017-07-31T00:00:00+10:00"/> <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."/> <caseSensitive value="true"/> <valueSet value="http://hl7.org/fhir/ValueSet/v3-DocumentCompletion"/> <hierarchyMeaning value="is-a"/> <content value="complete"/> <concept> <code value="AU"/> <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"/> <display value="dictated"/> <definition value="A completion status in which information has been orally recorded but not yet transcribed."/> </concept> <concept> <code value="DO"/> <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"/> <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"/> <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"/> <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"/> <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"/> <display value="pre-authenticated"/> <definition value="A completion status in which a document is transcribed but not authenticated."/> </concept> <concept> <code value="UC"/> <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>
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.