R4 Ballot #1 (Mixed Normative/Trial use)

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4.3.2.33 HL7 v3 Code System DocumentCompletion

Vocabulary Work Group Maturity Level: N/AExternal Use Context: Any

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

Summary

Defining URL:http://hl7.org/fhir/v3/DocumentCompletion
Name:v3 Code System DocumentCompletion
Definition:

Identifies the current completion state of a clinical document.

OID:2.16.840.1.113883.5.33 (for OID based terminology systems)
Source ResourceXML / JSON

This Code system is used in the following value sets:

  • ProvenanceEventCurrentState-DC ( Specifies the state change of a target Act using DocuymentCompletion codes, from its previous state as a predecessor Act. For example, if the target Act is the result of a predecessor Act being "obsoleted" and replaced with the target Act, the source ProvenanceEventCurrentState Act code would be "obsoleted".)
  • v3 Code System DocumentCompletion ( Identifies the current completion state of a clinical document.)
  • ProvenanceActivityType (This value set contains representative Activity Type codes, which includes codes from the HL7 DocumentCompletion, ActStatus, and DataOperations code system, W3C PROV-DM and PROV-N concepts and display names, several HL7 Lifecycle Event codes for which there are agreed upon definitions, and non-duplicated codes from the HL7 Security and Privacy Ontology Operations codes.)

4.3.2.33.1 Code System Content

Release Date: 2018-04-01

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.