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

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## Requirements: RI.1.1.1.1 Evidence of Record Entry Originate/Retain Event (Function)

Page standards status: Informative

Statement N:

Maintain Evidence of Record Entry Originate/Retain Event

Description I:

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

Actors:
ehr Criteria N:

RI.1.1.1.1#01 | SHALL | The system SHALL audit each occurrence when a Record Entry is originated and retained.
RI.1.1.1.1#02 | SHALL | The system SHALL capture identity of the organization where Record Entry content is originated.
RI.1.1.1.1#03 | SHALL | The system SHALL capture identity of the patient who is subject of Record Entry content.
RI.1.1.1.1#04 | SHALL | The system SHALL capture identity of the individual(s) who performed the Action documented in Record Entry content.
RI.1.1.1.1#05 | SHALL | The system SHALL capture identity of the user who entered/authored Record Entry content.
RI.1.1.1.1#06 | SHALL | The system SHALL capture identity of the system application which originated Record Entry content.
RI.1.1.1.1#07 | conditional SHALL | IF the source of Record Entry content is a device, THEN the system SHALL capture identity of the device.
RI.1.1.1.1#08 | SHALL | The system SHALL capture the Action as evidenced by Record Entry content.
RI.1.1.1.1#09 | SHALL | The system SHALL capture the type of Record Event trigger (i.e., originate/retain).
RI.1.1.1.1#10 | SHALL | The system SHALL capture the date and time of Action occurrence as evidenced by Record Entry content.
RI.1.1.1.1#11 | SHALL | The system SHALL capture the date and time Record Entry content is originated.
RI.1.1.1.1#12 | MAY | The system MAY capture the duration of the Action evidenced by Record Entry content.
RI.1.1.1.1#13 | MAY | The system MAY capture the physical location of the Action evidenced by Record Entry content.
RI.1.1.1.1#14 | SHOULD | The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is originated.
RI.1.1.1.1#15 | MAY | The system MAY capture the rationale for the Action evidenced by Record Entry content.
RI.1.1.1.1#16 | MAY | The system MAY capture the rationale for originating Record Entry content.
RI.1.1.1.1#17 | conditional SHOULD | IF Record Entry content includes templates (boilerplate information) or copied (duplicated) information, THEN the system SHOULD capture the source of such content.