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 Transmit Event
Evidence of Record Entry Transmit Event includes key metadata, ensures health record integrity (and trust) and enables record audit.
| RI.1.1.8.1#01 | SHALL |
The system SHALL audit each occurrence when Record Entry content is transmitted. |
| RI.1.1.8.1#02 | SHALL |
The system SHALL capture identity of the organization from which Record Entry content is transmitted. |
| RI.1.1.8.1#03 | SHALL |
The system SHALL capture identity of the patient who is subject of Record Entry content transmitted. |
| RI.1.1.8.1#04 | SHALL |
The system SHALL capture identity of the user initiating transmission of Record Entry content. |
| RI.1.1.8.1#05 | SHALL |
The system SHALL capture identity of the system application which transmitted Record Entry content. |
| RI.1.1.8.1#06 | SHALL |
The system SHALL capture identity of the system application which received Record Entry content. |
| RI.1.1.8.1#07 | SHALL |
The system SHALL capture the type of Record Event trigger (i.e., transmit). |
| RI.1.1.8.1#08 | SHALL |
The system SHALL capture the date and time Record Entry content is transmitted. |
| RI.1.1.8.1#09 | SHOULD |
The system SHOULD capture identity of the location (i.e., network address) from which the Record Entry is transmitted/disclosed. |
| RI.1.1.8.1#10 | SHALL |
The system SHALL capture the location (network address) to which the Record Entry is transmitted/disclosed. |
| RI.1.1.8.1#11 | MAY |
The system MAY capture the rationale for transmitting Record Entry content. |
| RI.1.1.8.1#12 | SHALL |
The system SHALL capture the type of Record Entry content transmitted/disclosed (e.g., original, amended, updated data). |
| RI.1.1.8.1#13 | MAY |
The system MAY capture the data, document or other identifier for transmitted/disclosed Record Entry. |
| RI.1.1.8.1#14 | MAY |
The system MAY capture data elements for transmitted/disclosed Record Entry. |
| RI.1.1.8.1#15 | dependent SHALL |
The system SHALL capture when a Record Entry transmit occurrence is known to be a disclosure, according to scope of practice, organizational policy, and/or jurisdictional law. |
| RI.1.1.8.1#16 | SHOULD |
The system SHOULD capture known and applicable permissions regarding Record Entry content transmitted including confidentiality codes, patient consent authorizations, privacy policy pointers. |