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

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Requirements: RI.1.1.6.1 Evidence of Record Entry Output/Report Event (Function)

Active as of 2024-11-23
Statement N:

Maintain Evidence of Record Entry Output/Report Event

 Description I:

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

 Criteria N:
RI.1.1.6.1#01 SHALL

The system SHALL audit each occurrence when an output (e.g., report, screen shot) is generated from Record Entry content.
RI.1.1.6.1#02 SHALL

The system SHALL capture identity of the organization where output/report is generated from Record Entry content.
RI.1.1.6.1#03 SHALL

The system SHALL capture identity of the patient who is subject of the Record Entry(ies) populating the output/report generated.
RI.1.1.6.1#04 SHALL

The system SHALL capture identity of the user who generated the output/report of Record Entry content.
RI.1.1.6.1#05 SHALL

The system SHALL capture identity of the system application from which the output/report is generated.
RI.1.1.6.1#06 SHALL

The system SHALL capture the type of Record Event trigger (i.e., output/report).
RI.1.1.6.1#07 SHALL

The system SHALL capture the date and time the output/report is generated.
RI.1.1.6.1#08 SHOULD

The system SHOULD capture identity of the location (i.e., network address) where the output/report is generated.
RI.1.1.6.1#09 MAY

The system MAY capture the rationale for generating the output/report.
RI.1.1.6.1#10 MAY

The system MAY capture the data, document, or other identifier for the output/report generated.
RI.1.1.6.1#11 dependent SHALL

The system SHALL capture when a Record Entry content output/report occurrence is known to be a disclosure, according to scope of practice, organizational policy, and/or jurisdictional law.
RI.1.1.6.1#12 SHOULD

The system SHOULD capture known and applicable permissions regarding Record Entry content output/reported including confidentiality codes, patient consent authorizations, privacy policy pointers.