This part provides definition of terms used throughout this chapter. The intent of this part is to provide clarification on use and interpretation.
9.1.1.1. Addendum: An appendage to an existing document that contains supplemental information. The parent document remains in place and its content is unaltered.
9.1.1.2 Archived: A status in which a document has been stored off-line for long-term access.
9.1.1.3 Composite document: A document which consists of an original document and one or more addenda.
9.1.1.4 Document completion table: The following terms are used to describe the workflow status of a document:
9.1.1.4.1 Authenticated: A status in which a document or entry 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.
9.1.1.4.2 Canceled (deleted): A status in which a document has been "removed" from a patients record with no replacement. This is done when a document has been erroneously created or assigned to the incorrect patient.
9.1.1.4.3 Dictated: A status in which information has been orally recorded but not yet transcribed.
9.1.1.4.4 Documented: A 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.
9.1.1.4.5 In progress/assigned: A workflow status change in which the recipient has assigned the material to personnel to perform the task of transcription. The document remains in this state until the document is transcribed.
9.1.1.4.6 Incomplete: A status in which information is known to be missing from a transcribed document.
9.1.1.4.7 Legally authenticated: A status in which a document or entry has been signed manually or electronically by the individual who is legally responsible for that document or entry. This is the most mature state in the workflow process.
9.1.1.4.8 Pre-authenticated: A status in which a document is transcribed but not authenticated.
9.1.1.5 Edited document: A document that alters an existing document which had not been made available for patient care.
9.1.1.6 New or original document: The first version of a document. The original may or may not be final or authenticated. An original document should have a set of associated statuses to define its current condition.
9.1.1.7 Obsolete: A status in which a document has been replaced by a document which contains revised content.
9.1.1.8 Purged: A status in which a document is no longer available in this system.
9.1.1.9 Replacement document: A document that replaces an existing document. The original document becomes obsolete, but is still retained in the system for historical reference.
9.1.1.10 Restricted: A status in which access to a document has institutionally assigned limitations.
9.1.1.11 Revised document: This is not a supported trigger event. When a document has not been made available for patient care, the "Edit" trigger event (T07) may be used to accomplish this function. Once a document has been made available, revision is not allowed. Instead, a replacement is issued (T010) which contains the revised content, together with a notice that the original documentwhich it supersedes) remains but is now obsolete.
9.1.1.12 Transcription: A process of transforming dictated or otherwise documented information into an electronic format.