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9.5.1 TXA - transcription document header segment

The TXA segment contains information specific to a transcribed document but does not include the text of the document. The message is created as a result of a Document Change Status. This information is used to update other healthcare systems to identify reports that are available in the transcription system. By maintaining the TXA message information in these systems, the information is available when constructing queries to the transcription system requesting the full document text.

Figure 9-2. TXA attributes

SEQ

LEN

DT

OPT

RP/#

TBL#

ITEM#

ELEMENT NAME

1

4

SI

R



00914

Set ID- Document

2

30

IS

R


0270

00915

Document Type

3

2

ID

C


0191

00916

Document Content Presentation

4

26

TS

O



00917

Activity Date/Time

5

60

XCN

C



00918

Primary Activity Provider Code/Name

6

26

TS

O



00919

Origination Date/Time

7

26

TS

C



00920

Transcription Date/Time

8

26

TS

O

Y


00921

Edit Date/Time

9

60

XCN

O



00922

Originator Code/Name

10

60

XCN

O

Y


00923

Assigned Document Authenticator

11

48

XCN

C



00924

Transcriptionist Code/Name

12

30

EI

R



00925

Unique Document Number

13

30

ST

C



00926

Parent Document Number

14

22

EI

O

Y


00216

Placer Order Number

15

22

EI

O



00217

Filler Order Number

16

30

ST

O



00927

Unique Document File Name

17

2

ID

R


0271

00928

Document Completion Status

18

2

ID

O


0272

00929

Document Confidentiality Status

19

2

ID

O


0273

00930

Document Availability Status









20

2

ID

O


0275

00932

Document Storage Status

21

30

ST

C


00933

Document Change Reason

22

60

CM

C

Y


00934

Authentication Person, Time Stamp

23

60

XCN

O

Y


00935

Distributed Copies (Code and Name of Recipients)

9.5.2.0 TXA field definitions

9.5.1.1 Set ID (SI) 00914

Definition: This field contains a number that uniquely identifies this transaction for the purpose of adding, changing, or deleting the transaction.

9.5.1.2 Document type (IS) 00915

Definition: This field identifies the type of document (as defined in the transcription system). Refer to user-defined table 0270 - Document type for suggested values. The organization is free to add more entries.

User-defined Table 0270 - Document type

Value

Description

AR

Autopsyreport

CD

Cardiodiagnostics

CN

Consultation

DI

Diagnostic imaging

DS

Discharge summary

ED

Emergency department report

HP

History and physical examination

OP

Operative report

PC

Psychiatric consultation

PH

Psychiatric history and physical examination

PN

Procedure note

PR

Progress note

SP

Surgical pathology

TS

Transfer summary

9.5.1.3 Document content presentation (ID) 00916

Definition: This is a conditional field which is required whenever the message contains content as presented in one or more OBX segments. This field identifies the method by which this document was obtained or originated. Refer to HL7 table 0191 - Main type of referenced data for valid values.

Table 0191 - Main type of referenced data

Value

Description

SI

Scanned image

NS

Non-scanned image

SD

Scanned document

TX

Machine readable text document

FT

Formatted text

IM

Image data (new with HL7 v 2.3)

AU

Audio data (new with HL7 v 2.3)

AP

Other application data, typically uninterpreted binary data (new with HL7 v 2.3)

9.5.1.4 Activity date/time (TS) 00917

Definition: This field contains the date/time identified in the document as the date a procedure or activity was performed. This date can identify date of surgery, non-invasive procedure, consultation, examination, etc.

9.5.1.5 Primary activity provider code/name (XCN) 00918

Components: <ID number (ST)> ^<family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^<assigning authority (HD)> ^<name type code(ID)> ^<identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)>

Definition: This field contains the name of the person identified in the document as being responsible for performing the procedure or activity. This field includes the code and name (if available) of the caregiver. This field is conditional based upon the presence of a value in TXA-4-activity date.

9.5.1.6 Origination date/time (TS) 00919

Definition: This field contains the date and time the document was created (i.e., dictated, recorded, etc.).

9.5.1.7 Transcription date/time (TS) 00920

Definition: This field contains the date and time the input was actually transcribed. This field is conditional based upon the presence of a value in TXA-17-document status of anything except "dictated."

9.5.1.8 Edit date/time (TS) 00921

Definition: This field contains the date and time the document was edited.

9.5.1.9 Originator code/name (XCN) 00922

Components: <ID number (ST)> ^<family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^<assigning authority (HD)> ^<name type code(ID)> ^<identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)>

Definition: This field identifies the person who originated (i.e., dictated) the document. The document originator may differ from the person responsible for authenticating the document.

9.5.1.10 Assigned document authenticator (XCN) 00923

Components: <ID number (ST)> ^<family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^<assigning authority (HD)> ^<name type code(ID)> ^<identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)>

Definition: This field identifies the person(s) responsible for authenticating the document, who may differ from the originator. Multiple persons may be responsible for authentication, especially in teaching facilities. This field is allowed to repeat an undefined number of times.

9.5.1.11 Transcriptionist code/name (XCN) 00924

Components: <ID number (ST)> ^<family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^<assigning authority (HD)> ^<name type code(ID)> ^<identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)>

Definition: This field identifies the person transcribing the document. This is a conditional value; it is required on all transcribed documents.

9.5.1.12 Unique document number (EI) 00925

Components: <entity identifier (ST)> ^ <assigning authority (HD)>

Definition: This field contains a unique document identification number assigned by the sending system. This document number is used to assist the receiving system in matching future updates to the document, as well as to identify the document in a query. When the vendor does not provide a unique document ID number, some type of document identifier should be entered here, or the Unique Document File name should be utilized. Please refer to Section 2.4.5.36 in Chapter 2. Where the system does not customarily have a document filler number, this number could serve as that value, as well.

9.5.1.13 Parent document number (ST) 00926

Definition: This field contains a document number that identifies the parent document to which this document belongs. The parent document number can be used to assist the receiving system in matching future updates to this document.. This is a conditional field that is always required on T05, T06, T09, and T10 events.

9.5.1.14 Placer order number (EI) 00216

Components: <entity identifier (ST)> ^ <assigning authority (HD)>

Definition: This field is the placer application’s order number.

This is a composite field. The first component is a string of up to 15 characters that identifies an individual order (e.g., OBR). It is assigned by the placer (ordering application). It identifies an order uniquely among all orders from a particular ordering application. The second component contains the application ID of the placing application. The application ID is a string of up to six (6) characters that will be uniquely associated with an application. A given institution or group of intercommunicating institutions should establish a unique list of applications that may be potential placers and fillers and assign unique application IDs. The two components are separated by a component delimiter.

9.5.1.15 Filler order number (EI) 00217

Components: <entity identifier (ST)> ^ <assigning authority (HD)>

Definition: This field is the order number associated with the filling application. Where a transcription service or similar organization creates the document and uses an internally unique identifier, that number should be inserted in this field. Its first component is a string of up to 15 characters that identifies an order detail segment (e.g., OBR). This string must uniquely identify the order (as specified in the order detail segment) from other orders in a particular filling application (e.g., transcription service). This uniqueness must persist over time. Where a number is reused over time, a date can be affixed to the non-unique number to make it unique.

The second component contains the filler application ID. The filler application ID is a string of up to six characters that uniquely defines the application from other applications on the network. The second component of the filler order number always identifies the actual filler of an order.

9.5.1.16 For further details, please see the definitions provided in Chapter 4.Unique document file name (ST) 00927

Definition: This field contains a unique name assigned to a document by the sending system. The file name is used to assist the receiving system in matching future updates to the document.

9.5.1.17 Document completion status (ID) 00928

Definition: This field identifies the current state of the document. This is a required, table-driven field. Refer to HL7 table 0271 - Document completion status for valid values.

Table 0271 - Document completion status

Value

Description

DI

Dictated

DO

Documented

IP

In Progress

IN

Incomplete

PA

Pre-authenticated

AU

Authenticated



LA

Legally authenticated

Figure 9-3. Document completion status state transition table

Transition (Action)

Old State

New State

Notes

T01 Original Notification

T02 Original Notification and Content

NA

Dictated

In Progress

Incomplete

Pre-authenticated

Authenticated

Legally authenticated


T03 Status Change Notification

T04 Status Change Notification and Content

Dictated

In Progress

Incomplete

Pre-authenticated

Authenticated

Legally authenticated



In Progress

Incomplete

Pre-authenticated

Authenticated

Legally authenticated



Incomplete

Pre-authenticated

Authenticated

Legally authenticated



Pre-authenticated

Authenticated

Legally authenticated



Authenticated

Legally authenticated



Legally authenticated

NA



Documented

Pre-authenticated

Authenticated

Legally authenticated


T05 Addendum Notification

T06 Addendum Notification and Content

NA

Dictated

In Progress

Incomplete

Pre-authenticated

Authenticated

Legally authenticated


T07 Edit Notification

T08 Edit Notification and Content

Dictated

In Progress

Incomplete

Pre-authenticated

Authenticated

Legally authenticated



In Progress

Incomplete

Pre-authenticated

Authenticated

Legally authenticated



Incomplete

Pre-authenticated

Authenticated

Legally authenticated



Pre-authenticated

Authenticated

Legally authenticated



Authenticated

Legally authenticated



Legally authenticated

NA



Documented

Pre-authenticated

Authenticated

Legally authenticated


T09 Replacement Notification

T10 Replacement Notification and Content

NA

Dictated

In Progress

Incomplete

Pre-authenticated

Authenticated

Legally authenticated


Note: NA means not applicable.

9.5.1.18 Document confidentiality status (ID) 00929

Definition: This is an optional field which identifies the degree to which special confidentiality protection should be applied to this information. The assignment of data elements to these categories is left to the discretion of the healthcare organization. Refer to HL7 table 0272 - Document confidentiality status for valid values.

Table 0272 - Document confidentiality status

Value

Description

VR

Very restricted

RE

Restricted

UC

Usual control

9.5.1.19 Document availability status (ID) 00930

Definition: This is an optional field which identifies a document’s availability for use in patient care. If an organization’s business rules allow a document to be used for patient care before it is authenticated, the value of this field should be set to "Available." Once a document has been made available for patient care, its content cannot be changed. Additional information must be provided via an addendum, which is separately authenticated and date/time stamped. If the content of a document whose status is "available" must be revised, this is done by issuing a replacement, which is separately authenticated and date/time stamped. Refer to HL7 table 0273 - Document availability status for valid values.

Table 0273 - Document availability status

Value

Description

AV

Available for patient care

DE

Deleted

OB

Obsolete

UN

Unavailable for patient care

Figure 9-4. Document availability status state transition table

Transition (Action)

Old State

New State

Notes

T01 Original Notification

T02 Original Notification and Content

NA

Unavailable

Available


T03 Status Change Notification

T04 Status Change Notification and Content

Unavailable

Unavailable

Available

Obsolete



Available

Available

Obsolete



Obsolete

NA


T05 Addendum Notification

T06 Addendum Notification and Content

NA

Unavailable

Available


T07 Edit Notification

T08 Edit Notification and Content

Unavailable

Unavailable

Available


T09 Replacement Notification

T10 Replacement Notification and Content

NA

Unavailable

Available

Set parent document to "obsolete"

T11 Cancel

Unavailable

Delete


Note: NA means not applicable.

9.5.1.20 Document storage status (ID) 00932

Definition: This optional field identifies the storage status of the document. Refer to HL7 table 0275 - Document storage status for valid values.

Table 0275 - Document storage status

Value

Description

AC

Active

AA

Active and archived

AR

Archived (not active)

PU

Purged

9.5.1.21 Document change reason (ST) 00933

Definition: This freetext field (limited to 30 characters) contains the reason for document status change.

9.5.1.22 Authentication person, time stamp (set) (CM) 00934

Components: <authenticated by whom (XCN)> ^ <when authenticated (TS)>

Definition: This is a conditional field. When the status of TXA-document completion status is equal to AU (authenticated) or LA (legally authenticated), both components are required. This field contains a set of two components describing by whom and when authentication was performed. Whenever the person component is valued, the second component, which is time stamp, must be valued as non-null. If the time component of a set is valued as non-null, the person component becomes required. These subcomponents are normally delimited by an ampersand (&). See Chapter 2.

9.5.1.22.1 Authentication person (component) (XCN)

Components: <ID number (ST)> ^<family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^<assigning authority (HD)> ^<name type code(ID)> ^<identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)>

Definition: This component identifies the person who has authenticated the document (either manually or electronically).

9.5.1.22.2 Authentication time stamp (component) (TS)

Definition: This component contains the date and time the document was authenticated (either manually or electronically).

9.5.1.23 Distributed copies (XCN) 00935

Components: <ID number (ST)> ^<family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^<assigning authority (HD)> ^<name type code(ID)> ^<identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)>

Definition: This field identifies the persons who received a copy of this document.

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