ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
2.1.0 - CI Build
ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
2.1.0 - CI Build
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| Active as of 2024-11-23 |
Maintain Evidence of Record Entry Translate Event
Evidence of Record Entry Translate Event includes key metadata, ensures health record integrity (and trust) and enables record audit.
| RI.1.1.3.1#01 | SHALL |
The system SHALL audit each occurrence when Record Entry content is translated. |
| RI.1.1.3.1#02 | SHALL |
The system SHALL capture identity of the organization where Record Entry content is translated. |
| RI.1.1.3.1#03 | SHALL |
The system SHALL capture identity of the patient who is subject of translated Record Entry content. |
| RI.1.1.3.1#04 | conditional SHALL |
IF a user initiated a Record Entry content translation, THEN the system SHALL capture identity of the user initiating Record Entry content translation. |
| RI.1.1.3.1#05 | SHALL |
The system SHALL capture identity of the system application which translated Record Entry content. |
| RI.1.1.3.1#06 | SHALL |
The system SHALL capture the type of Record Event trigger (i.e., translation). |
| RI.1.1.3.1#07 | SHALL |
The system SHALL capture the date and time Record Entry content is translated. |
| RI.1.1.3.1#08 | SHOULD |
The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is translated. |
| RI.1.1.3.1#09 | conditional MAY |
IF a user initiated a Record Entry translation, THEN the system MAY capture the rationale for translating Record Entry content. |
| RI.1.1.3.1#10 | SHALL |
The system SHALL capture a sequence identifier for translated Record Entry content. |
| RI.1.1.3.1#11 | SHALL |
The system SHALL capture the identifier and version of Translation Tools used for each translated Record Entry. |
| RI.1.1.3.1#12 | SHALL |
The system SHALL capture a reference (e.g., link, pointer) to pre-translation data for each Record Entry translation. |