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 |
Maintain Evidence of Record Entry View/Access Event
Evidence of Record Entry View/Access Event includes key metadata, ensures health record integrity (and trust) and enables record audit.
| RI.1.1.5.1#01 | SHALL |
The system SHALL audit each occurrence when Record Entry content is viewed/accessed. |
| RI.1.1.5.1#02 | SHALL |
The system SHALL capture identity of the organization where Record Entry content is viewed/accessed. |
| RI.1.1.5.1#03 | SHALL |
The system SHALL capture identity of the patient who is subject of the viewed/accessed Record Entry content. |
| RI.1.1.5.1#04 | SHALL |
The system SHALL capture identity of the user who viewed/accessed Record Entry content. |
| RI.1.1.5.1#05 | SHALL |
The system SHALL capture identity of the system application in which Record Entry content is viewed/accessed. |
| RI.1.1.5.1#06 | SHALL |
The system SHALL capture the type of Record Event trigger (i.e., view/access). |
| RI.1.1.5.1#07 | SHALL |
The system SHALL capture the date and time Record Entry content is viewed/accessed. |
| RI.1.1.5.1#08 | SHOULD |
The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is viewed/accessed. |
| RI.1.1.5.1#09 | MAY |
The system MAY capture the rationale for viewing/accessing Record Entry content (e.g., emergency access). |
| RI.1.1.5.1#10 | SHALL |
The system SHALL capture the data, document or other identifier for the viewed/accessed Record Entry content. |
| RI.1.1.5.1#11 | MAY |
The system MAY capture whether the data/document viewed/accessed is a primary source record (e.g., patient's record) or an aggregated report (e.g., summary report including multiple patients). |
| RI.1.1.5.1#12 | dependent SHALL |
The system SHALL capture when a Record Entry content view/access occurrence is known to be a disclosure, according to scope of practice, organizational policy, and/or jurisdictional law. |
| RI.1.1.5.1#13 | SHOULD |
The system SHOULD capture known and applicable permissions regarding Record Entry content viewed/accessed including confidentiality codes, patient consent authorizations, privacy policy pointers. |