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 |
{
"resourceType" : "Requirements",
"id" : "EHRSFMR2.1-RI.1.3.3",
"meta" : {
"profile" : [
🔗 "http://hl7.org/ehrs/StructureDefinition/FMFunction"
]
},
"text" : {
"status" : "extensions",
"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>Manage successive Record Entry versions over time.</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>The system must have a mechanism to handle versions and succession of Record Entries (such as a preliminary and final laboratory reports, amended or corrected documents). Versioning and succession management is based on Record Entry content, and/or status change over time.</p>\n<p>A version may be one of:1) A completed and attested Record Entry; 2) A Record Entry completed and attested which has been modified one or more times3) A Record Entry that has been viewed for clinical decision-making purposes by an individual other than the author4) A Record Entry that has been captured in an incomplete state per organization business rules and updated over time (i.e., a preliminary laboratory test). 5) A Record Entry that electively, according to the author, must be preserved in the current state at a given point in time (i.e., History and Physical). Certain types of Record Entries are typically handled in versions, for example:\nlaboratory results (preliminary and final)- Dictated reports- Work ups (over course of days)The prior version of Record Entries should be retained for the legally prescribed timeframe as defined by scope of practice, organizational policy, and jurisdictional law.</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.1.3.3#01</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 manage Record Entries that become new versions when their state changes (e.g., augmented, amended, corrected, etc.).</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.3.3#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 provide the ability to update a Record Entry and save it as a new version.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.3.3#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, maintain and render the date, time and user for the original and each updated version 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.1.3.3#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 manage the succession of Record Entries in chronological version order.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n </table>\n</div>"
},
"url" : "http://hl7.org/ehrs/Requirements/EHRSFMR2.1-RI.1.3.3",
"version" : "0.16.0",
"name" : "RI_1_3_3_Manage_Record_Entry_Succession_and_Version_Control",
"title" : "RI.1.3.3 Manage Record Entry Succession and Version Control (Function)",
"status" : "active",
"date" : "2024-08-12T10:56:01+00:00",
"publisher" : "EHR WG",
"contact" : [
{
"telecom" : [
{
"system" : "url",
"value" : "http://www.hl7.org/Special/committees/ehr"
}
]
}
],
"description" : "Manage successive Record Entry versions over time.",
"purpose" : "The system must have a mechanism to handle versions and succession of Record Entries (such as a preliminary and final laboratory reports, amended or corrected documents). Versioning and succession management is based on Record Entry content, and/or status change over time.\n\nA version may be one of:1) A completed and attested Record Entry; 2) A Record Entry completed and attested which has been modified one or more times3) A Record Entry that has been viewed for clinical decision-making purposes by an individual other than the author4) A Record Entry that has been captured in an incomplete state per organization business rules and updated over time (i.e., a preliminary laboratory test). 5) A Record Entry that electively, according to the author, must be preserved in the current state at a given point in time (i.e., History and Physical). Certain types of Record Entries are typically handled in versions, for example:\n laboratory results (preliminary and final)- Dictated reports- Work ups (over course of days)The prior version of Record Entries should be retained for the legally prescribed timeframe as defined by scope of practice, organizational policy, and jurisdictional law.",
"statement" : [
{
"extension" : [
{
"url" : "http://hl7.org/ehrs/StructureDefinition/requirements-dependent",
"valueBoolean" : false
}
],
"key" : "EHRSFMR2.1-RI.1.3.3-01",
"label" : "RI.1.3.3#01",
"conformance" : [
"SHOULD"
],
"conditionality" : false,
"requirement" : "The system SHOULD provide the ability to manage Record Entries that become new versions when their state changes (e.g., augmented, amended, corrected, etc.)."
},
{
"extension" : [
{
"url" : "http://hl7.org/ehrs/StructureDefinition/requirements-dependent",
"valueBoolean" : false
}
],
"key" : "EHRSFMR2.1-RI.1.3.3-02",
"label" : "RI.1.3.3#02",
"conformance" : [
"SHALL"
],
"conditionality" : false,
"requirement" : "The system SHALL provide the ability to update a Record Entry and save it as a new version."
},
{
"extension" : [
{
"url" : "http://hl7.org/ehrs/StructureDefinition/requirements-dependent",
"valueBoolean" : false
}
],
"key" : "EHRSFMR2.1-RI.1.3.3-03",
"label" : "RI.1.3.3#03",
"conformance" : [
"SHALL"
],
"conditionality" : false,
"requirement" : "The system SHALL capture, maintain and render the date, time and user for the original and each updated version of the Record Entry."
},
{
"extension" : [
{
"url" : "http://hl7.org/ehrs/StructureDefinition/requirements-dependent",
"valueBoolean" : false
}
],
"key" : "EHRSFMR2.1-RI.1.3.3-04",
"label" : "RI.1.3.3#04",
"conformance" : [
"SHALL"
],
"conditionality" : false,
"requirement" : "The system SHALL manage the succession of Record Entries in chronological version order."
}
]
}