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 Disclosure Event
Evidence of Record Entry Disclosure Event includes key metadata, ensures health record integrity (and trust) and enables record audit.
RI.1.1.7.1#01 | dependent SHALL |
The system SHALL audit each occurrence when Record Entry content is disclosed according to scope of practice, organizational policy, and/or jurisdictional law. |
RI.1.1.7.1#02 | SHALL |
The system SHALL capture identity of the organization from which Record Entry content is disclosed. |
RI.1.1.7.1#03 | SHALL |
The system SHALL capture identity of the patient who is subject of Record Entry content disclosed. |
RI.1.1.7.1#04 | SHALL |
The system SHALL capture identity of the user initiating disclosure of Record Entry content. |
RI.1.1.7.1#05 | SHALL |
The system SHALL capture identity of the system application from which Record Entry content is disclosed. |
RI.1.1.7.1#06 | SHALL |
The system SHALL capture the type of Record Event trigger (i.e., disclose). |
RI.1.1.7.1#07 | SHALL |
The system SHALL capture the date and time Record Entry content is disclosed. |
RI.1.1.7.1#08 | SHOULD |
The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is disclosed. |
RI.1.1.7.1#09 | SHOULD |
The system SHOULD capture the rationale for disclosing Record Entry content. |
RI.1.1.7.1#10 | MAY |
The system MAY capture the data, document or other identifier for Record Entry content disclosed. |
RI.1.1.7.1#11 | dependent SHALL |
The system SHALL capture that this is an occurrence when Record Entry content is known to be disclosed, according to scope of practice, organizational policy, and/or jurisdictional law. |
RI.1.1.7.1#12 | SHOULD |
The system SHOULD capture known and applicable permissions regarding Record Entry content disclosed including confidentiality codes, patient consent authorizations, privacy policy pointers. |