HL7 Electronic Health Record System Functional Model, Release 2.1.1
2.1.1 - International flag

HL7 Electronic Health Record System Functional Model, Release 2.1.1, published by HL7 International / Electronic Health Records. This guide is not an authorized publication; it is the continuous build for version 2.1.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/mvdzel/ehrsfm-fhir-r5/ and changes regularly. See the Directory of published versions

Requirements: RI.1.1.1.1 Evidence of Record Entry Originate/Retain Event (Function)

Official URL: http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-RI.1.1.1.1 Version: 2.1.1
Standards status: Normative Active as of 2025-10-31 Computable Name: RI_1_1_1_1_Evidence_of_Record_Entry_Originate_Retain_Event

Maintain Evidence of Record Entry Originate/Retain Event

Statement N:

Maintain Evidence of Record Entry Originate/Retain Event

Description I:

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

Criteria N:
RI.1.1.1.1#01
SHALL

The system SHALL audit each occurrence when a Record Entry is originated and retained.
RI.1.1.1.1#02
SHALL

The system SHALL capture identity of the organization where Record Entry content is originated.
RI.1.1.1.1#03
SHALL

The system SHALL capture identity of the patient who is subject of Record Entry content.
RI.1.1.1.1#04
SHALL

The system SHALL capture identity of the individual(s) who performed the Action documented in Record Entry content.
RI.1.1.1.1#05
SHALL

The system SHALL capture identity of the user who entered/authored Record Entry content.
RI.1.1.1.1#06
SHALL

The system SHALL capture identity of the system application which originated Record Entry content.
RI.1.1.1.1#07
 conditional
SHALL

IF the source of Record Entry content is a device, THEN the system SHALL capture identity of the device.
RI.1.1.1.1#08
SHALL

The system SHALL capture the Action as evidenced by Record Entry content.
RI.1.1.1.1#09
SHALL

The system SHALL capture the type of Record Event trigger (i.e., originate/retain).
RI.1.1.1.1#10
SHALL

The system SHALL capture the date and time of Action occurrence as evidenced by Record Entry content.
RI.1.1.1.1#11
SHALL

The system SHALL capture the date and time Record Entry content is originated.
RI.1.1.1.1#12
MAY

The system MAY capture the duration of the Action evidenced by Record Entry content.
RI.1.1.1.1#13
MAY

The system MAY capture the physical location of the Action evidenced by Record Entry content.
RI.1.1.1.1#14
SHOULD

The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is originated.
RI.1.1.1.1#15
MAY

The system MAY capture the rationale for the Action evidenced by Record Entry content.
RI.1.1.1.1#16
MAY

The system MAY capture the rationale for originating Record Entry content.
RI.1.1.1.1#17
 conditional
SHOULD

IF Record Entry content includes templates (boilerplate information) or copied (duplicated) information, THEN the system SHOULD capture the source of such content.