Lower Extremity Skin Wound Assessment Implementation Guide STU1 CI Build

Lower Extremity Skin Wound Assessment - IG, published by HL7 International - Electronic Health Records Work Group. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/fhir-skin-wound-ig/ and changes regularly. See the Directory of published versions

RLE Mapping

This section provides the key Record Lifecycle Event Metadata mapping requirements to the FHIR security FHIR AuditEvent (R4) and FHIR Provenance (R4) resource types.

The conformance verbs used are defined in FHIR Conformance Rules.


Contents


Record Lifecycle Event Metadata Mapping

The following Record Lifecycle Event Metadata mappings are intended to facilitate the development and implementation of the recording of these events within all Lower Extremity Skin Wound Assessment actor systems used in this guide. The Record Lifecycle Events Metadata mappings covered in this page are:

  • 15.1.2 Record lifecycle event - Originate/retain record entry instance(s)
  • 15.2.2 Record lifecycle event - Amend (update) record entry instance(s)
  • 15.9 Record lifecycle event - Receive/retain record entry instance(s)

Additional RLE mappings will be provided in subsequent updates to this guide.


AuditEvent Mapping

Originate/retain

ID Conformance
Verb
Conformance
Criteria
FHIR
Resource
RLE
Mapping
cc1 SHALL Who - Record Entry Subject - Individual Subject of Care ID AuditEvent WHO / Patient
cc2 SHALL Who - Accountable Health/care Party(ies), if applicable:    
cc3 SHOULD - Digital Signature    
cc4 SHALL - Organization ID/Descriptor AuditEvent WHO / Organization
cc5 SHALL - Business Unit ID/Descriptor AuditEvent WHO / Organization
cc6 SHALL - Individual Healthcare Professional, Caregiver ID AuditEvent WHO / Action - Performer
cc7 SHOULD - Role - relative to organization, business unit AuditEvent WHO / Action - Performer
cc8 SHOULD - Role - relative to Record Entry Instance: e.g. author, scribe/proxy, verifier AuditEvent WHO / Action - Performer
cc9 SHOULD - Role - relative to individual author of content AuditEvent WHO / Action - Performer
cc10 SHOULD - Scope of accountability AuditEvent WHO / Action - Performer
cc11 SHALL Who - Accountable Health/care Agent(s), if applicable:    
cc12 SHOULD - Digital Signature    
cc13 SHALL - Device, application or software ID AuditEvent WHO / Record - System/Device
cc14 SHOULD - Role - relative to Record Entry Instance: originator, source AuditEvent WHO / Record - System/Device
cc15 SHOULD - Scope of accountability AuditEvent WHO / Record - System/Device
cc16 SHALL What - Action Instance ID AuditEvent WHAT / Action - Taken
cc17 SHALL What - Record Entry Instance ID AuditEvent Add’l / Record Entry ID
cc18 SHALL What - Record Entry Lifecycle Event: originate AuditEvent WHAT / Record - Lifecycle Event
cc19 SHALL What - Record Entry instance status: e.g. new, updated, verified AuditEvent outcome (FHIR element)
cc20 SHALL What - Record Entry completion status: e.g. documented, dictated (pre-transcription), in progress, incomplete, pre-authenticated, authenticated, legally authenticated (ref: HL7) AuditEvent outcome (FHIR element)
cc21 SHALL When - Record Entry origination date/time AuditEvent WHEN / Action - Date/Time
WHEN / Record - Date/Time
cc22 SHALL Where - Record Entry physical location, point of origination AuditEvent WHERE / Action - Physical Location
cc23 SHALL Where - network address    
cc24 SHOULD Why - rationale or purpose for Record Entry origination AuditEvent WHY / Action - Reason, Rationale, Purpose
WHY / Record - Reason, Rationale, Purpose

Amend (update)

ID Conformance
Verb
Conformance
Criteria
FHIR
Resource
RLE
Mapping
cc1 SHALL Who - Record Entry Subject - Individual Subject of Care ID AuditEvent WHO / Patient
cc2 SHALL Who - Accountable Health/care Party(ies), if applicable:    
cc3 SHOULD - Digital Signature    
cc4 SHALL - Organization ID/Descriptor AuditEvent WHO / Organization
cc5 SHALL - Business Unit ID/Descriptor AuditEvent WHO / Organization
cc6 SHALL - Individual Healthcare Professional, Caregiver ID AuditEvent WHO / Action - Performer
cc7 SHOULD - Role - relative to organization, business unit AuditEvent WHO / Action - Performer
cc8 SHOULD - Role - relative to Record Entry Instance: e.g. author, scribe/proxy AuditEvent WHO / Action - Performer
cc9 SHOULD - Role - relative to individual author of content AuditEvent WHO / Action - Performer
cc10 SHOULD - Scope of accountability AuditEvent WHO / Action - Performer
cc11 SHALL What - Action Instance ID AuditEvent WHAT / Action - Taken
cc12 SHALL What - Record Entry Instance ID AuditEvent Add’l / Record Entry ID
cc13 SHALL What - Record Entry Lifecycle Event: update AuditEvent WHAT / Record - Lifecycle Event
cc14 SHALL What - Record Entry instance status: e.g. updated AuditEvent outcome (FHIR element)
cc15 SHALL What - Record Entry completion status AuditEvent outcome (FHIR element)
cc16 SHALL When - Record Entry update date/time AuditEvent WHEN / Action - Date/Time
WHEN / Record - Date/Time
cc17 SHALL Where - Record Entry physical location, point of update AuditEvent WHERE / Action - Physical Location
cc18 SHALL Where - network address    
cc19 SHOULD Why - rationale or purpose for Record Entry update AuditEvent WHY / Action - Reason, Rationale, Purpose
WHY / Record - Reason, Rationale, Purpose

Receive/retain

ID Conformance
Verb
Conformance
Criteria
FHIR
Resource
RLE
Mapping
cc1 SHALL Who - Record Entry Subject - Individual Subject of Care ID AuditEvent WHO / Patient
cc2 SHALL Who - Source/Sender - Reporter, Discloser, Transmitter - Accountable Health/care Party(ies), if applicable:    
cc3 SHALL - Organization ID/Descriptor AuditEvent WHO / Organization
cc4 SHALL - Business Unit ID/Descriptor AuditEvent WHO / Organization
cc5 SHALL - Individual Healthcare Professional, Caregiver ID AuditEvent WHO / Action - Performer
cc6 SHALL Who - Intended Recipient - Accountable Health/care Party(ies), if applicable:    
cc7 SHALL - Organization ID/Descriptor AuditEvent WHO / Organization
cc8 SHALL - Business Unit ID/Descriptor AuditEvent WHO / Organization
cc9 SHALL - Individual Healthcare Professional, Caregiver ID AuditEvent WHO / Action - Performer
cc10 SHOULD - Role - relative to organization, business unit AuditEvent WHO / Action - Performer
cc11 SHOULD - Role - relative to Record Entry Instance: e.g. recipient AuditEvent WHO / Action - Performer
cc12 SHOULD - Scope of accountability AuditEvent WHO / Action - Performer
cc13 SHALL Who - Accountable Health/care Agent(s), if applicable:    
cc14 SHOULD - Digital Signature    
cc15 SHALL - Device, application or software ID AuditEvent WHO / Record - System/Device
cc16 SHOULD - Role - relative to Record Entry Instance: e.g. receiver AuditEvent WHO / Record - System/Device
cc17 SHOULD - Scope of accountability AuditEvent WHO / Record - System/Device
cc18 SHALL What - Action Instance ID AuditEvent WHAT / Action - Taken
cc19 SHALL What - Record Entry Instance ID(s) AuditEvent Add’l / Record Entry ID
cc20 SHALL What - Record Entry Lifecycle Event: receipt AuditEvent WHAT / Record - Lifecycle Event
cc21 SHALL What - Record Entry instance status: e.g. received AuditEvent outcome
cc22 SHALL What - Record Entry completion status: e.g. completed AuditEvent outcome
cc23 SHALL When - Record Entry: e.g. date/time of receipt AuditEvent WHEN / Action - Date/Time
WHEN / Record - Date/Time
cc24 SHALL Where - Record Entry physical location: e.g. point of receipt AuditEvent WHERE / Action - Physical Location
cc25 SHALL Where - network address    
cc26 SHOULD Why - rationale or purpose for Record Entry receipt AuditEvent WHY / Action - Reason, Rationale, Purpose
WHY / Record - Reason, Rationale, Purpose


Provenance Mapping

Originate/retain

ID Conformance
Verb
Conformance
Criteria
FHIR
Resource
RLE
Mapping
cc1 SHALL Who - Record Entry Subject - Individual Subject of Care ID Provenance WHO / Patient
cc2 SHALL Who - Accountable Health/care Party(ies), if applicable:    
cc3 SHOULD - Digital Signature Provenance Add’l / Digital Signature(s)
cc4 SHALL - Organization ID/Descriptor Provenance WHO / Organization
cc5 SHALL - Business Unit ID/Descriptor Provenance WHO / Organization
cc6 SHALL - Individual Healthcare Professional, Caregiver ID Provenance WHO / Action - Performer
cc7 SHOULD - Role - relative to organization, business unit Provenance WHO / Action - Performer
cc8 SHOULD - Role - relative to Record Entry Instance: e.g. author, scribe/proxy, verifier Provenance WHO / Action - Performer
cc9 SHOULD - Role - relative to individual author of content Provenance WHO / Action - Performer
cc10 SHOULD - Scope of accountability Provenance WHO / Action - Performer
cc11 SHALL Who - Accountable Health/care Agent(s), if applicable:    
cc12 SHOULD - Digital Signature Provenance Add’l / Digital Signature(s)
cc13 SHALL - Device, application or software ID Provenance WHO / Record - System/Device
cc14 SHOULD - Role - relative to Record Entry Instance: originator, source Provenance WHO / Record - System/Device
cc15 SHOULD - Scope of accountability Provenance WHO / Record - System/Device
cc16 SHALL What - Action Instance ID Provenance WHAT / Action - Taken
cc17 SHALL What - Record Entry Instance ID Provenance Add’l / Record Entry ID
cc18 SHALL What - Record Entry Lifecycle Event: originate    
cc19 SHALL What - Record Entry instance status: e.g. new, updated, verified    
cc20 SHALL What - Record Entry completion status: e.g. documented, dictated (pre-transcription), in progress, incomplete, pre-authenticated, authenticated, legally authenticated (ref: HL7)    
cc21 SHALL When - Record Entry origination date/time Provenance WHEN / Action - Date/Time
WHEN / Record - Date/Time
cc22 SHALL Where - Record Entry physical location, point of origination    
cc23 SHALL Where - network address Provenance WHERE / Record - Network Address
cc24 SHOULD Why - rationale or purpose for Record Entry origination Provenance WHY / Action - Reason, Rationale, Purpose
WHY / Record - Reason, Rationale, Purpose

Amend (update)

ID Conformance
Verb
Conformance
Criteria
FHIR
Resource
RLE
Mapping
cc1 SHALL Who - Record Entry Subject - Individual Subject of Care ID Provenance WHO / Patient
cc2 SHALL Who - Accountable Health/care Party(ies), if applicable:    
cc3 SHOULD - Digital Signature Provenance Add’l / Digital Signature(s)
cc4 SHALL - Organization ID/Descriptor Provenance WHO / Organization
cc5 SHALL - Business Unit ID/Descriptor Provenance WHO / Organization
cc6 SHALL - Individual Healthcare Professional, Caregiver ID Provenance WHO / Action - Performer
cc7 SHOULD - Role - relative to organization, business unit Provenance WHO / Action - Performer
cc8 SHOULD - Role - relative to Record Entry Instance: e.g. author, scribe/proxy Provenance WHO / Action - Performer
cc9 SHOULD - Role - relative to individual author of content Provenance WHO / Action - Performer
cc10 SHOULD - Scope of accountability Provenance WHO / Action - Performer
cc11 SHALL What - Action Instance ID Provenance WHAT / Action - Taken
cc12 SHALL What - Record Entry Instance ID Provenance Add’l / Record Entry ID
cc13 SHALL What - Record Entry Lifecycle Event: update    
cc14 SHALL What - Record Entry instance status: e.g. updated    
cc15 SHALL What - Record Entry completion status    
cc16 SHALL When - Record Entry update date/time Provenance WHEN / Action - Date/Time
WHEN / Record - Date/Time
cc17 SHALL Where - Record Entry physical location, point of update    
cc18 SHALL Where - network address Provenance WHERE / Record - Network Address
cc19 SHOULD Why - rationale or purpose for Record Entry update Provenance WHY / Action - Reason, Rationale, Purpose
WHY / Record - Reason, Rationale, Purpose

Receive/retain

ID Conformance
Verb
Conformance
Criteria
FHIR
Resource
RLE
Mapping
cc1 SHALL Who - Record Entry Subject - Individual Subject of Care ID Provenance WHO / Patient
cc2 SHALL Who - Source/Sender - Reporter, Discloser, Transmitter - Accountable Health/care Party(ies), if applicable:    
cc3 SHALL - Organization ID/Descriptor Provenance WHO / Organization
cc4 SHALL - Business Unit ID/Descriptor Provenance WHO / Organization
cc5 SHALL - Individual Healthcare Professional, Caregiver ID Provenance WHO / Action - Performer
cc6 SHALL Who - Intended Recipient- Accountable Health/care Party(ies), if applicable:    
cc7 SHALL - Organization ID/Descriptor Provenance WHO / Organization
cc8 SHALL - Business Unit ID/Descriptor Provenance WHO / Organization
cc9 SHALL - Individual Healthcare Professional, Caregiver ID Provenance WHO / Action - Performer
cc10 SHOULD - Role - relative to organization, business unit Provenance WHO / Action - Performer
cc11 SHOULD - Role - relative to Record Entry Instance: e.g. recipient Provenance WHO / Action - Performer
cc12 SHOULD - Scope of accountability Provenance WHO / Action - Performer
cc13 SHALL Who - Accountable Health/care Agent(s), if applicable:    
cc14 SHOULD - Digital Signature Provenance Add’l / Digital Signature(s)
cc15 SHALL - Device, application or software ID Provenance WHO / Record - System/Device
cc16 SHOULD - Role - relative to Record Entry Instance: e.g. receiver Provenance WHO / Record - System/Device
cc17 SHOULD - Scope of accountability Provenance WHO / Record - System/Device
cc18 SHALL What - Action Instance ID Provenance WHAT / Action - Taken
cc19 SHALL What - Record Entry Instance ID(s) Provenance Add’l / Record Entry ID
cc20 SHALL What - Record Entry Lifecycle Event: receipt    
cc21 SHALL What - Record Entry instance status: e.g. received    
cc22 SHALL What - Record Entry completion status: e.g. completed    
cc23 SHALL When - Record Entry: e.g. date/time of receipt Provenance WHEN / Action - Date/Time
WHEN / Record - Date/Time
cc24 SHALL Where - Record Entry physical location: e.g. point of receipt    
cc25 SHALL Where - network address Provenance WHERE / Record - Network Address
cc26 SHOULD Why - rationale or purpose for Record Entry receipt Provenance WHY / Action - Reason, Rationale, Purpose
WHY / Record - Reason, Rationale, Purpose

US Core Provenance Mapping