ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
0.14.0 - CI Build
ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
0.14.0 - CI Build
ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1 - Local Development build (v0.14.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Active as of 2024-06-01 |
Originate and Retain Record Entry (1 instance)
Occurs when an agent causes the system to: a) initiate capture of potential record content, and b) incorporate that content into the storage considered a permanent part of the health record.
Reference: ISO 21089-2018, Section 15.1.
| RI.1.1.1#01 | SHALL |
The system SHALL provide the ability to capture (originate) a Record Entry instance corresponding to an Action instance and context. |
| RI.1.1.1#02 | SHALL |
The system SHALL capture a unique instance identifier for each Record Entry. |
| RI.1.1.1#03 | SHALL |
The system SHALL capture the signature event (e.g., digital signature) of the origination entry Author, binding signature to Record Entry content. |
| RI.1.1.1#04 | SHALL |
The system SHALL provide the ability to capture both structured and unstructured content in Record Entries. |
| RI.1.1.1#05 | SHALL |
The system SHALL provide the ability to capture Record Entries from information recorded during system downtime. |
| RI.1.1.1#06 | SHOULD |
The system SHOULD provide the ability to integrate Record Entries from Information recorded during system downtime. |
| RI.1.1.1#07 | SHALL |
The system SHALL provide the ability to capture the date/time an Action was taken or data was collected if different than date/time of the Record Entry. |
| RI.1.1.1#08 | SHOULD |
The system SHOULD capture metadata that identifies the source of non-originated Record Entry (e.g., templated, copied, duplicated, or boilerplate information). |
| RI.1.1.1#09 | MAY |
The system MAY provide the ability to tag unstructured Record Entry content to organize it according to need, for example, in a time-related fashion or by application-specific groups (such as photographs, handwritten notes, or auditory sounds), or by order of relative importance. |
| RI.1.1.1#10 | MAY |
The system MAY capture and maintain a Record Entry encoded as a standards-based data object (e.g., HL7 Continuity of Care, other HL7 CDA R2 Document, ISO 13606 artifact). |
| RI.1.1.1#11 | MAY |
The system MAY capture and maintain a standards-based data object to mirror (be duplicate and synchronous with) internal Record Entry representation. |