{ "resourceType" : "Requirements", "id" : "DHFPR2-RI.1.1.1", "meta" : { "profile" : ["http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMFunction"] }, "language" : "en", "text" : { "status" : "extensions", "div" : "
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Description I:

Occurs when an agent causes the system to: a) initiate capture of potential record content, and b) incorporate that content into the storage considered a permanent part of the health record.

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Reference: ISO 21089-2018, Section 15.1.

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Criteria N:
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\n RI.1.1.1#01\n \n SHALL\n \n \n \n \n \n \n \n \n

The system SHALL provide the ability to capture (originate) a Record Entry instance corresponding to an Action instance and context.

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\n RI.1.1.1#02\n \n SHALL\n \n \n \n \n \n \n \n \n

The system SHALL capture a unique instance identifier for each Record Entry.

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\n RI.1.1.1#03\n \n SHALL\n \n \n \n \n \n \n \n \n

The system SHALL capture the signature event (e.g., digital signature) of the origination entry Author, binding signature to Record Entry content.

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\n RI.1.1.1#04\n \n SHALL\n \n \n \n \n \n \n \n \n

The system SHALL provide the ability to capture both structured and unstructured content in Record Entries.

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\n RI.1.1.1#05\n \n SHALL\n \n \n \n \n \n \n \n \n

The system SHALL provide the ability to capture Record Entries from information recorded during system downtime.

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\n RI.1.1.1#06\n \n SHOULD\n \n \n \n \n \n \n \n \n

The system SHOULD provide the ability to integrate Record Entries from Information recorded during system downtime.

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\n RI.1.1.1#07\n \n SHALL\n \n \n \n \n \n \n \n \n

The system SHALL provide the ability to capture the date/time an Action was taken or data was collected if different than date/time of the Record Entry.

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\n RI.1.1.1#08\n \n SHOULD\n \n \n \n \n \n \n \n \n

The system SHOULD capture metadata that identifies the source of non-originated Record Entry (e.g., templated, copied, duplicated, or boilerplate information).

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\n RI.1.1.1#09\n \n MAY\n \n \n \n \n \n \n \n \n

The system MAY provide the ability to tag unstructured Record Entry content to organize it according to need, for example, in a time-related fashion or by application-specific groups (such as photographs, handwritten notes, or auditory sounds), or by order of relative importance.

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\n RI.1.1.1#10\n \n MAY\n \n \n \n \n \n \n \n \n

The system MAY capture and maintain a Record Entry encoded as a standards-based data object (e.g., HL7 Continuity of Care, other HL7 CDA R2 Document, ISO 13606 artifact).

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\n RI.1.1.1#11\n \n MAY\n \n \n \n \n \n \n \n \n

The system MAY capture and maintain a standards-based data object to mirror (be duplicate and synchronous with) internal Record Entry representation.

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" }, "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status", "valueCode" : "informative" }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }, { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg", "valueCode" : "ehr" }, { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm", "valueInteger" : 1, "_valueInteger" : { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom", "valueCanonical" : "http://hl7.org/ehrs/us/dhfpr2/ImplementationGuide/hl7.ehrs.us.dhfpr2" }] } }], "url" : "http://hl7.org/ehrs/us/dhfpr2/Requirements/DHFPR2-RI.1.1.1", "version" : "2.0.0-ballot", "name" : "RI_1_1_1_Originate_Retain_Record_Lifecycle_Event", "title" : "RI.1.1.1 Originate/Retain Record Lifecycle Event (Function)", "status" : "active", "date" : "2025-12-19T08:44:27+00:00", "publisher" : "HL7 International / Electronic Health Records", "contact" : [{ "telecom" : [{ "system" : "url", "value" : "http://www.hl7.org/Special/committees/ehr" }] }], "description" : "Originate and Retain Record Entry (1 instance)", "jurisdiction" : [{ "coding" : [{ "system" : "urn:iso:std:iso:3166", "code" : "US" }] }], "purpose" : "Occurs when an agent causes the system to: a) initiate capture of potential record content, and b) incorporate that content into the storage considered a permanent part of the health record. \n\nReference: ISO 21089-2018, Section 15.1.", "derivedFrom" : ["http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-RI.1.1.1"], "statement" : [{ "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-RI.1.1.1-01", "label" : "RI.1.1.1#01", "conformance" : ["SHALL"], "conditionality" : false, "requirement" : "The system SHALL provide the ability to capture (originate) a Record Entry instance corresponding to an Action instance and context.", "derivedFrom" : "RI.1.1.1#1" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-RI.1.1.1-02", "label" : "RI.1.1.1#02", "conformance" : ["SHALL"], "conditionality" : false, "requirement" : "The system SHALL capture a unique instance identifier for each Record Entry.", "derivedFrom" : "RI.1.1.1#2" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-RI.1.1.1-03", "label" : "RI.1.1.1#03", "conformance" : ["SHALL"], "conditionality" : false, "requirement" : "The system SHALL capture the signature event (e.g., digital signature) of the origination entry Author, binding signature to Record Entry content.", "derivedFrom" : "RI.1.1.1#3" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-RI.1.1.1-04", "label" : "RI.1.1.1#04", "conformance" : ["SHALL"], "conditionality" : false, "requirement" : "The system SHALL provide the ability to capture both structured and unstructured content in Record Entries.", "derivedFrom" : "RI.1.1.1#4" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-RI.1.1.1-05", "label" : "RI.1.1.1#05", "conformance" : ["SHALL"], "conditionality" : false, "requirement" : "The system SHALL provide the ability to capture Record Entries from information recorded during system downtime.", "derivedFrom" : "RI.1.1.1#5" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-RI.1.1.1-06", "label" : "RI.1.1.1#06", "conformance" : ["SHOULD"], "conditionality" : false, "requirement" : "The system SHOULD provide the ability to integrate Record Entries from Information recorded during system downtime.", "derivedFrom" : "RI.1.1.1#6" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-RI.1.1.1-07", "label" : "RI.1.1.1#07", "conformance" : ["SHALL"], "conditionality" : false, "requirement" : "The system SHALL provide the ability to capture the date/time an Action was taken or data was collected if different than date/time of the Record Entry.", "derivedFrom" : "RI.1.1.1#7" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-RI.1.1.1-08", "label" : "RI.1.1.1#08", "conformance" : ["SHOULD"], "conditionality" : false, "requirement" : "The system SHOULD capture metadata that identifies the source of non-originated Record Entry (e.g., templated, copied, duplicated, or boilerplate information).", "derivedFrom" : "RI.1.1.1#8" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-RI.1.1.1-09", "label" : "RI.1.1.1#09", "conformance" : ["MAY"], "conditionality" : false, "requirement" : "The system MAY provide the ability to tag unstructured Record Entry content to organize it according to need, for example, in a time-related fashion or by application-specific groups (such as photographs, handwritten notes, or auditory sounds), or by order of relative importance.", "derivedFrom" : "RI.1.1.1#9" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-RI.1.1.1-10", "label" : "RI.1.1.1#10", "conformance" : ["MAY"], "conditionality" : false, "requirement" : "The system MAY capture and maintain a Record Entry encoded as a standards-based data object (e.g., HL7 Continuity of Care, other HL7 CDA R2 Document, ISO 13606 artifact).", "derivedFrom" : "RI.1.1.1#10" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-RI.1.1.1-11", "label" : "RI.1.1.1#11", "conformance" : ["MAY"], "conditionality" : false, "requirement" : "The system MAY capture and maintain a standards-based data object to mirror (be duplicate and synchronous with) internal Record Entry representation.", "derivedFrom" : "RI.1.1.1#11" }] }