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

This page is part of the HL7 Electronic Health Record System Functional Model, Release 2.1.1 (v2.1.1-ballot: Normative 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. No current official version has been published yet. For a full list of available versions, see the Directory of published versions

Requirements: RI.1.1.8.1 Evidence of Record Entry Transmit Event (Function)

Page standards status: Informative
Statement N:

Maintain Evidence of Record Entry Transmit Event

 Description I:

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

 Actors:
ehr Criteria N:
RI.1.1.8.1#01 SHALL

The system SHALL audit each occurrence when Record Entry content is transmitted.
RI.1.1.8.1#02 SHALL

The system SHALL capture identity of the organization from which Record Entry content is transmitted.
RI.1.1.8.1#03 SHALL

The system SHALL capture identity of the patient who is subject of Record Entry content transmitted.
RI.1.1.8.1#04 SHALL

The system SHALL capture identity of the user initiating transmission of Record Entry content.
RI.1.1.8.1#05 SHALL

The system SHALL capture identity of the system application which transmitted Record Entry content.
RI.1.1.8.1#06 SHALL

The system SHALL capture identity of the system application which received Record Entry content.
RI.1.1.8.1#07 SHALL

The system SHALL capture the type of Record Event trigger (i.e., transmit).
RI.1.1.8.1#08 SHALL

The system SHALL capture the date and time Record Entry content is transmitted.
RI.1.1.8.1#09 SHOULD

The system SHOULD capture identity of the location (i.e., network address) from which the Record Entry is transmitted/disclosed.
RI.1.1.8.1#10 SHALL

The system SHALL capture the location (network address) to which the Record Entry is transmitted/disclosed.
RI.1.1.8.1#11 MAY

The system MAY capture the rationale for transmitting Record Entry content.
RI.1.1.8.1#12 SHALL

The system SHALL capture the type of Record Entry content transmitted/disclosed (e.g., original, amended, updated data).
RI.1.1.8.1#13 MAY

The system MAY capture the data, document or other identifier for transmitted/disclosed Record Entry.
RI.1.1.8.1#14 MAY

The system MAY capture data elements for transmitted/disclosed Record Entry.
RI.1.1.8.1#15 dependent SHALL

The system SHALL capture when a Record Entry transmit occurrence is known to be a disclosure, according to scope of practice, organizational policy, and/or jurisdictional law.
RI.1.1.8.1#16 SHOULD

The system SHOULD capture known and applicable permissions regarding Record Entry content transmitted including confidentiality codes, patient consent authorizations, privacy policy pointers.