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

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## 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.