ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
2.1.0 - local
ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
2.1.0 - local
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| Active as of 2024-11-26 |
Maintain Evidence of Record Entry Originate/Retain Event
Evidence of Record Entry Originate/Retain Event includes key metadata, ensures health record integrity (and trust) and enables record audit.
| RI.1.1.1.1#01 | SHALL |
The system SHALL audit each occurrence when a Record Entry is originated and retained. |
| RI.1.1.1.1#02 | SHALL |
The system SHALL capture identity of the organization where Record Entry content is originated. |
| RI.1.1.1.1#03 | SHALL |
The system SHALL capture identity of the patient who is subject of Record Entry content. |
| RI.1.1.1.1#04 | SHALL |
The system SHALL capture identity of the individual(s) who performed the Action documented in Record Entry content. |
| RI.1.1.1.1#05 | SHALL |
The system SHALL capture identity of the user who entered/authored Record Entry content. |
| RI.1.1.1.1#06 | SHALL |
The system SHALL capture identity of the system application which originated Record Entry content. |
| RI.1.1.1.1#07 | conditional SHALL |
IF the source of Record Entry content is a device, THEN the system SHALL capture identity of the device. |
| RI.1.1.1.1#08 | SHALL |
The system SHALL capture the Action as evidenced by Record Entry content. |
| RI.1.1.1.1#09 | SHALL |
The system SHALL capture the type of Record Event trigger (i.e., originate/retain). |
| RI.1.1.1.1#10 | SHALL |
The system SHALL capture the date and time of Action occurrence as evidenced by Record Entry content. |
| RI.1.1.1.1#11 | SHALL |
The system SHALL capture the date and time Record Entry content is originated. |
| RI.1.1.1.1#12 | MAY |
The system MAY capture the duration of the Action evidenced by Record Entry content. |
| RI.1.1.1.1#13 | MAY |
The system MAY capture the physical location of the Action evidenced by Record Entry content. |
| RI.1.1.1.1#14 | SHOULD |
The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is originated. |
| RI.1.1.1.1#15 | MAY |
The system MAY capture the rationale for the Action evidenced by Record Entry content. |
| RI.1.1.1.1#16 | MAY |
The system MAY capture the rationale for originating Record Entry content. |
| RI.1.1.1.1#17 | conditional SHOULD |
IF Record Entry content includes templates (boilerplate information) or copied (duplicated) information, THEN the system SHOULD capture the source of such content. |