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

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Requirements: RI.1.1.7.1 Evidence of Record Entry Disclosure Event (Function)

Active as of 2024-11-23
Statement N:

Maintain Evidence of Record Entry Disclosure Event

 Description I:

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

 Criteria N:
RI.1.1.7.1#01 dependent SHALL

The system SHALL audit each occurrence when Record Entry content is disclosed according to scope of practice, organizational policy, and/or jurisdictional law.
RI.1.1.7.1#02 SHALL

The system SHALL capture identity of the organization from which Record Entry content is disclosed.
RI.1.1.7.1#03 SHALL

The system SHALL capture identity of the patient who is subject of Record Entry content disclosed.
RI.1.1.7.1#04 SHALL

The system SHALL capture identity of the user initiating disclosure of Record Entry content.
RI.1.1.7.1#05 SHALL

The system SHALL capture identity of the system application from which Record Entry content is disclosed.
RI.1.1.7.1#06 SHALL

The system SHALL capture the type of Record Event trigger (i.e., disclose).
RI.1.1.7.1#07 SHALL

The system SHALL capture the date and time Record Entry content is disclosed.
RI.1.1.7.1#08 SHOULD

The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is disclosed.
RI.1.1.7.1#09 SHOULD

The system SHOULD capture the rationale for disclosing Record Entry content.
RI.1.1.7.1#10 MAY

The system MAY capture the data, document or other identifier for Record Entry content disclosed.
RI.1.1.7.1#11 dependent SHALL

The system SHALL capture that this is an occurrence when Record Entry content is known to be disclosed, according to scope of practice, organizational policy, and/or jurisdictional law.
RI.1.1.7.1#12 SHOULD

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