ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
2.1.0 - local
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 |
<Requirements xmlns="http://hl7.org/fhir">
<id value="EHRSFMR2.1-RI.1.3.3"/>
<meta>
<profile value="http://hl7.org/ehrs/StructureDefinition/FMFunction"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<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>
</div></span>
<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>
<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:
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.</p>
</div></span>
<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>
<table id="statements" class="grid dict">
<tr>
<td style="padding-left: 4px;">
<span>RI.1.3.3#01</span>
</td>
<td style="padding-left: 4px;">
<span>SHOULD</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<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>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>RI.1.3.3#02</span>
</td>
<td style="padding-left: 4px;">
<span>SHALL</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system SHALL provide the ability to update a Record Entry and save it as a new version.</p>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>RI.1.3.3#03</span>
</td>
<td style="padding-left: 4px;">
<span>SHALL</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<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>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>RI.1.3.3#04</span>
</td>
<td style="padding-left: 4px;">
<span>SHALL</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system SHALL manage the succession of Record Entries in chronological version order.</p>
</div></span>
</td>
</tr>
</table>
</div>
</text>
<url value="http://hl7.org/ehrs/Requirements/EHRSFMR2.1-RI.1.3.3"/>
<version value="2.1.0"/>
<name value="RI_1_3_3_Manage_Record_Entry_Succession_and_Version_Control"/>
<title
value="RI.1.3.3 Manage Record Entry Succession and Version Control (Function)"/>
<status value="active"/>
<date value="2024-11-26T16:30:50+00:00"/>
<publisher value="EHR WG"/>
<contact>
<telecom>
<system value="url"/>
<value value="http://www.hl7.org/Special/committees/ehr"/>
</telecom>
</contact>
<description value="Manage successive Record Entry versions over time."/>
<jurisdiction>
<coding>
<system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
<code value="001"/>
<display value="World"/>
</coding>
</jurisdiction>
<purpose
value="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.
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:
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 value="false"/>
</extension>
<key value="EHRSFMR2.1-RI.1.3.3-01"/>
<label value="RI.1.3.3#01"/>
<conformance value="SHOULD"/>
<conditionality value="false"/>
<requirement
value="The system SHOULD provide the ability to manage Record Entries that become new versions when their state changes (e.g., augmented, amended, corrected, etc.)."/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-RI.1.3.3-02"/>
<label value="RI.1.3.3#02"/>
<conformance value="SHALL"/>
<conditionality value="false"/>
<requirement
value="The system SHALL provide the ability to update a Record Entry and save it as a new version."/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-RI.1.3.3-03"/>
<label value="RI.1.3.3#03"/>
<conformance value="SHALL"/>
<conditionality value="false"/>
<requirement
value="The system SHALL capture, maintain and render the date, time and user for the original and each updated version of the Record Entry."/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-RI.1.3.3-04"/>
<label value="RI.1.3.3#04"/>
<conformance value="SHALL"/>
<conditionality value="false"/>
<requirement
value="The system SHALL manage the succession of Record Entries in chronological version order."/>
</statement>
</Requirements>