ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
2.1.0 - CI Build

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Requirements: RI.1.1.2.1 Evidence of Record Entry Amendment Event (Function)

Active as of 2024-11-23
Statement N:

Maintain Evidence of Record Entry Amendment Event

 Description I:

Evidence of Record Entry Amendment Event includes key metadata, ensures health record integrity (and trust) and enables record audit.

 Criteria N:
RI.1.1.2.1#01 SHALL

The system SHALL audit each occurrence when a Record Entry is amended.
RI.1.1.2.1#02 SHALL

The system SHALL capture identity of the organization where Record Entry content is amended.
RI.1.1.2.1#03 SHALL

The system SHALL capture identity of the patient who is subject of amended Record Entry content.
RI.1.1.2.1#04 SHALL

The system SHALL capture identity of the user who entered/authored Record Entry content amendment.
RI.1.1.2.1#05 SHALL

The system SHALL capture identity of the system application which amended Record Entry content.
RI.1.1.2.1#06 SHALL

The system SHALL capture the type of Record Event trigger (i.e., amendment).
RI.1.1.2.1#07 SHALL

The system SHALL capture the date and time Record Entry content is amended.
RI.1.1.2.1#08 SHOULD

The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is amended.
RI.1.1.2.1#09 SHOULD

The system SHOULD capture the rationale for amending Record Entry content.
RI.1.1.2.1#10 SHALL

The system SHALL capture a sequence identifier for amended Record Entry content.
RI.1.1.2.1#11 SHOULD

The system SHOULD capture a reference (e.g., link, pointer) to pre-amendment data for each amended Record Entry.