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 Receive/Retain Event
Evidence of Record Entry Receive/Retain Event includes key metadata, ensures health record integrity (and trust) and enables record audit.
| RI.1.1.9.1#01 | SHALL |
The system SHALL audit each occurrence when externally-sourced Record Entry content is received and retained. |
| RI.1.1.9.1#02 | SHALL |
The system SHALL capture identity of the organization transmitting Record Entry content received and retained. |
| RI.1.1.9.1#03 | SHALL |
The system SHALL capture identity of the organization receiving transmitted Record Entry content. |
| RI.1.1.9.1#04 | SHALL |
The system SHALL capture identity of the patient who is subject of received Record Entry content. |
| RI.1.1.9.1#05 | conditional SHALL |
IF the system supports user verification of receipt of externally-sourced Record Entry content, THEN the system SHALL capture identity of the user accepting receipt of the transmitted Record Entry content. |
| RI.1.1.9.1#06 | SHALL |
The system SHALL capture identity of the system application which transmitted Record Entry content. |
| RI.1.1.9.1#07 | SHALL |
The system SHALL capture identity of the system application which received Record Entry content. |
| RI.1.1.9.1#08 | SHALL |
The system SHALL capture the type of Record Event trigger (i.e., receive). |
| RI.1.1.9.1#09 | SHALL |
The system SHALL capture the date and time Record Entry content is received. |
| RI.1.1.9.1#10 | SHOULD |
The system SHOULD capture identity of the location (i.e., network address) where the Record Entry content is received. |
| RI.1.1.9.1#11 | MAY |
The system MAY capture the rationale for accepting receipt of transmitted Record Entry content. |
| RI.1.1.9.1#12 | SHALL |
The system SHALL capture the type of Record Entry content received (e.g., original, amended, updated data). |
| RI.1.1.9.1#13 | conditional MAY |
IF an internal identifier is assigned to data/documents received from an external source, THEN the system MAY capture the data, document or other identifier for the Record Entry received. |
| RI.1.1.9.1#14 | MAY |
The system MAY capture data elements for the Record Entry received. |