ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
0.16.0 - CI Build
ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
0.16.0 - CI Build
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| Active as of 2024-08-12 |
@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"] ; #
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>Originate and Retain Record Entry (1 instance)</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>Occurs when an agent causes the system to: a) initiate capture of potential record content, and b) incorporate that content into the storage considered a permanent part of the health record.</p>\n<p>Reference: ISO 21089-2018, Section 15.1.</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#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 provide the ability to capture (originate) a Record Entry instance corresponding to an Action instance and context.</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#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 a unique instance identifier for each Record Entry.</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#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 the signature event (e.g., digital signature) of the origination entry Author, binding signature to 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#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 provide the ability to capture both structured and unstructured content in Record Entries.</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#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 provide the ability to capture Record Entries from information recorded during system downtime.</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#06</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 provide the ability to integrate Record Entries from Information recorded during system downtime.</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#07</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 provide the ability to capture the date/time an Action was taken or data was collected if different than date/time of the Record Entry.</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#08</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 metadata that identifies the source of non-originated Record Entry (e.g., templated, copied, duplicated, or boilerplate information).</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#09</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 provide the ability to tag unstructured Record Entry content to organize it according to need, for example, in a time-related fashion or by application-specific groups (such as photographs, handwritten notes, or auditory sounds), or by order of relative importance.</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#10</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 and maintain a Record Entry encoded as a standards-based data object (e.g., HL7 Continuity of Care, other HL7 CDA R2 Document, ISO 13606 artifact).</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#11</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 and maintain a standards-based data object to mirror (be duplicate and synchronous with) internal Record Entry representation.</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"^^xsd:anyURI] ; #
fhir:version [ fhir:v "0.16.0"] ; #
fhir:name [ fhir:v "RI_1_1_1_Originate_Retain_Record_Lifecycle_Event"] ; #
fhir:title [ fhir:v "RI.1.1.1 Originate/Retain Record Lifecycle Event (Function)"] ; #
fhir:status [ fhir:v "active"] ; #
fhir:date [ fhir:v "2024-08-12T10:56:01+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 "Originate and Retain Record Entry (1 instance)"] ; #
fhir:purpose [ fhir:v "Occurs when an agent causes the system to: a) initiate capture of potential record content, and b) incorporate that content into the storage considered a permanent part of the health record. \n\nReference: ISO 21089-2018, Section 15.1."] ; #
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.1.1.1-01" ] ;
fhir:label [ fhir:v "RI.1.1.1#01" ] ;
( fhir:conformance [ fhir:v "SHALL" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHALL provide the ability to capture (originate) a Record Entry instance corresponding to an Action instance and context." ] ;
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.1.1.1-02" ] ;
fhir:label [ fhir:v "RI.1.1.1#02" ] ;
( fhir:conformance [ fhir:v "SHALL" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHALL capture a unique instance identifier for each Record Entry." ] ;
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.1.1.1-03" ] ;
fhir:label [ fhir:v "RI.1.1.1#03" ] ;
( fhir:conformance [ fhir:v "SHALL" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHALL capture the signature event (e.g., digital signature) of the origination entry Author, binding signature to 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.1.1.1-04" ] ;
fhir:label [ fhir:v "RI.1.1.1#04" ] ;
( fhir:conformance [ fhir:v "SHALL" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHALL provide the ability to capture both structured and unstructured content in Record Entries." ]
] [
( 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.1.1.1-05" ] ;
fhir:label [ fhir:v "RI.1.1.1#05" ] ;
( fhir:conformance [ fhir:v "SHALL" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHALL provide the ability to capture Record Entries from information recorded during system downtime." ]
] [
( 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.1.1.1-06" ] ;
fhir:label [ fhir:v "RI.1.1.1#06" ] ;
( fhir:conformance [ fhir:v "SHOULD" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHOULD provide the ability to integrate Record Entries from Information recorded during system downtime." ]
] [
( 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.1.1.1-07" ] ;
fhir:label [ fhir:v "RI.1.1.1#07" ] ;
( fhir:conformance [ fhir:v "SHALL" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHALL provide the ability to capture the date/time an Action was taken or data was collected if different than date/time of the Record Entry." ] ;
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.1.1.1-08" ] ;
fhir:label [ fhir:v "RI.1.1.1#08" ] ;
( fhir:conformance [ fhir:v "SHOULD" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHOULD capture metadata that identifies the source of non-originated Record Entry (e.g., templated, copied, duplicated, or boilerplate information)." ]
] [
( 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.1.1.1-09" ] ;
fhir:label [ fhir:v "RI.1.1.1#09" ] ;
( fhir:conformance [ fhir:v "MAY" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system MAY provide the ability to tag unstructured Record Entry content to organize it according to need, for example, in a time-related fashion or by application-specific groups (such as photographs, handwritten notes, or auditory sounds), or by order of relative importance." ]
] [
( 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.1.1.1-10" ] ;
fhir:label [ fhir:v "RI.1.1.1#10" ] ;
( fhir:conformance [ fhir:v "MAY" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system MAY capture and maintain a Record Entry encoded as a standards-based data object (e.g., HL7 Continuity of Care, other HL7 CDA R2 Document, ISO 13606 artifact)." ]
] [
( 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.1.1.1-11" ] ;
fhir:label [ fhir:v "RI.1.1.1#11" ] ;
( fhir:conformance [ fhir:v "MAY" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system MAY capture and maintain a standards-based data object to mirror (be duplicate and synchronous with) internal Record Entry representation." ]
] ) . #
IG © 2023 EHR WG. Package hl7.ehrsfmr21.base#0.16.0 based on FHIR 5.0.0. Generated 2024-08-12
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