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 Output/Report Event
Evidence of Record Entry Output/Report Event includes key metadata, ensures health record integrity (and trust) and enables record audit.
RI.1.1.6.1#01 | SHALL |
The system SHALL audit each occurrence when an output (e.g., report, screen shot) is generated from Record Entry content. |
RI.1.1.6.1#02 | SHALL |
The system SHALL capture identity of the organization where output/report is generated from Record Entry content. |
RI.1.1.6.1#03 | SHALL |
The system SHALL capture identity of the patient who is subject of the Record Entry(ies) populating the output/report generated. |
RI.1.1.6.1#04 | SHALL |
The system SHALL capture identity of the user who generated the output/report of Record Entry content. |
RI.1.1.6.1#05 | SHALL |
The system SHALL capture identity of the system application from which the output/report is generated. |
RI.1.1.6.1#06 | SHALL |
The system SHALL capture the type of Record Event trigger (i.e., output/report). |
RI.1.1.6.1#07 | SHALL |
The system SHALL capture the date and time the output/report is generated. |
RI.1.1.6.1#08 | SHOULD |
The system SHOULD capture identity of the location (i.e., network address) where the output/report is generated. |
RI.1.1.6.1#09 | MAY |
The system MAY capture the rationale for generating the output/report. |
RI.1.1.6.1#10 | MAY |
The system MAY capture the data, document, or other identifier for the output/report generated. |
RI.1.1.6.1#11 | dependent SHALL |
The system SHALL capture when a Record Entry content output/report occurrence is known to be a disclosure, according to scope of practice, organizational policy, and/or jurisdictional law. |
RI.1.1.6.1#12 | SHOULD |
The system SHOULD capture known and applicable permissions regarding Record Entry content output/reported including confidentiality codes, patient consent authorizations, privacy policy pointers. |