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 |
@prefix fhir: <http://hl7.org/fhir/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- a fhir:Requirements ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "EHRSFMR2.1-RI.1.1.1.1"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/ehrs/StructureDefinition/FMFunction"^^xsd:anyURI ; fhir:link <http://hl7.org/ehrs/StructureDefinition/FMFunction> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "extensions" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span id=\"description\"><b>Statement <a href=\"https://hl7.org/fhir/versions.html#std-process\" title=\"Normative Content\" class=\"normative-flag\">N</a>:</b> <div><p>Maintain Evidence of Record Entry Originate/Retain Event</p>\n</div></span>\n\n \n <span id=\"purpose\"><b>Description <a href=\"https://hl7.org/fhir/versions.html#std-process\" title=\"Informative Content\" class=\"informative-flag\">I</a>:</b> <div><p>Evidence of Record Entry Originate/Retain Event includes key metadata, ensures health record integrity (and trust) and enables record audit.</p>\n</div></span>\n \n\n \n\n \n <span id=\"requirements\"><b>Criteria <a href=\"https://hl7.org/fhir/versions.html#std-process\" title=\"Normative Content\" class=\"normative-flag\">N</a>:</b></span>\n \n <table id=\"statements\" class=\"grid dict\">\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#01</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHALL</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHALL audit each occurrence when a Record Entry is originated and retained.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#02</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHALL</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHALL capture identity of the organization where Record Entry content is originated.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#03</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHALL</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHALL capture identity of the patient who is subject of Record Entry content.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#04</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHALL</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHALL capture identity of the individual(s) who performed the Action documented in Record Entry content.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#05</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHALL</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHALL capture identity of the user who entered/authored Record Entry content.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#06</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHALL</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHALL capture identity of the system application which originated Record Entry content.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#07</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n <i>conditional</i>\n \n \n <span>SHALL</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>IF the source of Record Entry content is a device, THEN the system SHALL capture identity of the device.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#08</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHALL</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHALL capture the Action as evidenced by Record Entry content.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#09</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHALL</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHALL capture the type of Record Event trigger (i.e., originate/retain).</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#10</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHALL</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHALL capture the date and time of Action occurrence as evidenced by Record Entry content.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#11</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHALL</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHALL capture the date and time Record Entry content is originated.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#12</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>MAY</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system MAY capture the duration of the Action evidenced by Record Entry content.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#13</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>MAY</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system MAY capture the physical location of the Action evidenced by Record Entry content.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#14</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHOULD</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is originated.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#15</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>MAY</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system MAY capture the rationale for the Action evidenced by Record Entry content.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#16</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>MAY</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system MAY capture the rationale for originating Record Entry content.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.1.1.1#17</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n <i>conditional</i>\n \n \n <span>SHOULD</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>IF Record Entry content includes templates (boilerplate information) or copied (duplicated) information, THEN the system SHOULD capture the source of such content.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n </table>\n</div>" ] ; # fhir:url [ fhir:v "http://hl7.org/ehrs/Requirements/EHRSFMR2.1-RI.1.1.1.1"^^xsd:anyURI] ; # fhir:version [ fhir:v "2.1.0"] ; # fhir:name [ fhir:v "RI_1_1_1_1_Evidence_of_Record_Entry_Originate_Retain_Event"] ; # fhir:title [ fhir:v "RI.1.1.1.1 Evidence of Record Entry Originate/Retain Event (Function)"] ; # fhir:status [ fhir:v "active"] ; # fhir:date [ fhir:v "2024-11-26T16:30:50+00:00"^^xsd:dateTime] ; # fhir:publisher [ fhir:v "EHR WG"] ; # fhir:contact ( [ ( fhir:telecom [ fhir:system [ fhir:v "url" ] ; fhir:value [ fhir:v "http://www.hl7.org/Special/committees/ehr" ] ] ) ] ) ; # fhir:description [ fhir:v "Maintain Evidence of Record Entry Originate/Retain Event"] ; # fhir:jurisdiction ( [ ( fhir:coding [ fhir:system [ fhir:v "http://unstats.un.org/unsd/methods/m49/m49.htm"^^xsd:anyURI ] ; fhir:code [ fhir:v "001" ] ; fhir:display [ fhir:v "World" ] ] ) ] ) ; # fhir:purpose [ fhir:v "Evidence of Record Entry Originate/Retain Event includes key metadata, ensures health record integrity (and trust) and enables record audit."] ; # fhir:statement ( [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-01" ] ; fhir:label [ fhir:v "RI.1.1.1.1#01" ] ; ( fhir:conformance [ fhir:v "SHALL" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system SHALL audit each occurrence when a Record Entry is originated and retained." ] ; fhir:derivedFrom [ fhir:v "EHR-LM_R1 14.1" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-02" ] ; fhir:label [ fhir:v "RI.1.1.1.1#02" ] ; ( fhir:conformance [ fhir:v "SHALL" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system SHALL capture identity of the organization where Record Entry content is originated." ] ; fhir:derivedFrom [ fhir:v "EHR-LM_R1 14.1" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-03" ] ; fhir:label [ fhir:v "RI.1.1.1.1#03" ] ; ( fhir:conformance [ fhir:v "SHALL" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system SHALL capture identity of the patient who is subject of Record Entry content." ] ; fhir:derivedFrom [ fhir:v "EHR-LM_R1 14.1" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-04" ] ; fhir:label [ fhir:v "RI.1.1.1.1#04" ] ; ( fhir:conformance [ fhir:v "SHALL" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system SHALL capture identity of the individual(s) who performed the Action documented in Record Entry content." ] ; fhir:derivedFrom [ fhir:v "EHR-LM_R1 14.1" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-05" ] ; fhir:label [ fhir:v "RI.1.1.1.1#05" ] ; ( fhir:conformance [ fhir:v "SHALL" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system SHALL capture identity of the user who entered/authored Record Entry content." ] ; fhir:derivedFrom [ fhir:v "EHR-LM_R1 14.1" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-06" ] ; fhir:label [ fhir:v "RI.1.1.1.1#06" ] ; ( fhir:conformance [ fhir:v "SHALL" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system SHALL capture identity of the system application which originated Record Entry content." ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-07" ] ; fhir:label [ fhir:v "RI.1.1.1.1#07" ] ; ( fhir:conformance [ fhir:v "SHALL" ] ) ; fhir:conditionality [ fhir:v "true"^^xsd:boolean ] ; fhir:requirement [ fhir:v "IF the source of Record Entry content is a device, THEN the system SHALL capture identity of the device." ] ; fhir:derivedFrom [ fhir:v "EHR-LM_R1 14.1" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-08" ] ; fhir:label [ fhir:v "RI.1.1.1.1#08" ] ; ( fhir:conformance [ fhir:v "SHALL" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system SHALL capture the Action as evidenced by Record Entry content." ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-09" ] ; fhir:label [ fhir:v "RI.1.1.1.1#09" ] ; ( fhir:conformance [ fhir:v "SHALL" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system SHALL capture the type of Record Event trigger (i.e., originate/retain)." ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-10" ] ; fhir:label [ fhir:v "RI.1.1.1.1#10" ] ; ( fhir:conformance [ fhir:v "SHALL" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system SHALL capture the date and time of Action occurrence as evidenced by Record Entry content." ] ; fhir:derivedFrom [ fhir:v "EHR-LM_R1 14.1" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-11" ] ; fhir:label [ fhir:v "RI.1.1.1.1#11" ] ; ( fhir:conformance [ fhir:v "SHALL" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system SHALL capture the date and time Record Entry content is originated." ] ; fhir:derivedFrom [ fhir:v "EHR-LM_R1 14.1" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-12" ] ; fhir:label [ fhir:v "RI.1.1.1.1#12" ] ; ( fhir:conformance [ fhir:v "MAY" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system MAY capture the duration of the Action evidenced by Record Entry content." ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-13" ] ; fhir:label [ fhir:v "RI.1.1.1.1#13" ] ; ( fhir:conformance [ fhir:v "MAY" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system MAY capture the physical location of the Action evidenced by Record Entry content." ] ; fhir:derivedFrom [ fhir:v "EHR-LM_R1 14.1" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-14" ] ; fhir:label [ fhir:v "RI.1.1.1.1#14" ] ; ( fhir:conformance [ fhir:v "SHOULD" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is originated." ] ; fhir:derivedFrom [ fhir:v "EHR-LM_R1 14.1" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-15" ] ; fhir:label [ fhir:v "RI.1.1.1.1#15" ] ; ( fhir:conformance [ fhir:v "MAY" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system MAY capture the rationale for the Action evidenced by Record Entry content." ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-16" ] ; fhir:label [ fhir:v "RI.1.1.1.1#16" ] ; ( fhir:conformance [ fhir:v "MAY" ] ) ; fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ; fhir:requirement [ fhir:v "The system MAY capture the rationale for originating Record Entry content." ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; fhir:key [ fhir:v "EHRSFMR2.1-RI.1.1.1.1-17" ] ; fhir:label [ fhir:v "RI.1.1.1.1#17" ] ; ( fhir:conformance [ fhir:v "SHOULD" ] ) ; fhir:conditionality [ fhir:v "true"^^xsd:boolean ] ; fhir:requirement [ fhir:v "IF Record Entry content includes templates (boilerplate information) or copied (duplicated) information, THEN the system SHOULD capture the source of such content." ] ] ) . #
IG © 2024 EHR WG. Package hl7.ehrs.ehrsfmr21#2.1.0 based on FHIR 5.0.0. Generated 2024-11-26
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