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 |
Maintain Evidence of Record Entry Amendment Event
Evidence of Record Entry Amendment Event includes key metadata, ensures health record integrity (and trust) and enables record audit.
| RI.1.1.2.1#01 | SHALL |
The system SHALL audit each occurrence when a Record Entry is amended. |
| RI.1.1.2.1#02 | SHALL |
The system SHALL capture identity of the organization where Record Entry content is amended. |
| RI.1.1.2.1#03 | SHALL |
The system SHALL capture identity of the patient who is subject of amended Record Entry content. |
| RI.1.1.2.1#04 | SHALL |
The system SHALL capture identity of the user who entered/authored Record Entry content amendment. |
| RI.1.1.2.1#05 | SHALL |
The system SHALL capture identity of the system application which amended Record Entry content. |
| RI.1.1.2.1#06 | SHALL |
The system SHALL capture the type of Record Event trigger (i.e., amendment). |
| RI.1.1.2.1#07 | SHALL |
The system SHALL capture the date and time Record Entry content is amended. |
| RI.1.1.2.1#08 | SHOULD |
The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is amended. |
| RI.1.1.2.1#09 | SHOULD |
The system SHOULD capture the rationale for amending Record Entry content. |
| RI.1.1.2.1#10 | SHALL |
The system SHALL capture a sequence identifier for amended Record Entry content. |
| RI.1.1.2.1#11 | SHOULD |
The system SHOULD capture a reference (e.g., link, pointer) to pre-amendment data for each amended Record Entry. |