ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
2.1.0 - local International flag

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Requirements: RI.1.1.3.1 Evidence of Record Entry Translate Event (Function)

Active as of 2024-11-26
Statement N:

Maintain Evidence of Record Entry Translate Event

Description I:

Evidence of Record Entry Translate Event includes key metadata, ensures health record integrity (and trust) and enables record audit.

Criteria N:
RI.1.1.3.1#01 SHALL

The system SHALL audit each occurrence when Record Entry content is translated.

RI.1.1.3.1#02 SHALL

The system SHALL capture identity of the organization where Record Entry content is translated.

RI.1.1.3.1#03 SHALL

The system SHALL capture identity of the patient who is subject of translated Record Entry content.

RI.1.1.3.1#04 conditional SHALL

IF a user initiated a Record Entry content translation, THEN the system SHALL capture identity of the user initiating Record Entry content translation.

RI.1.1.3.1#05 SHALL

The system SHALL capture identity of the system application which translated Record Entry content.

RI.1.1.3.1#06 SHALL

The system SHALL capture the type of Record Event trigger (i.e., translation).

RI.1.1.3.1#07 SHALL

The system SHALL capture the date and time Record Entry content is translated.

RI.1.1.3.1#08 SHOULD

The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is translated.

RI.1.1.3.1#09 conditional MAY

IF a user initiated a Record Entry translation, THEN the system MAY capture the rationale for translating Record Entry content.

RI.1.1.3.1#10 SHALL

The system SHALL capture a sequence identifier for translated Record Entry content.

RI.1.1.3.1#11 SHALL

The system SHALL capture the identifier and version of Translation Tools used for each translated Record Entry.

RI.1.1.3.1#12 SHALL

The system SHALL capture a reference (e.g., link, pointer) to pre-translation data for each Record Entry translation.