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

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## Requirements: RI.1.1.3.1 Evidence of Record Entry Translate Event (Function)

Page standards status: Informative

Statement N:

Maintain Evidence of Record Entry Translate Event

Description I:

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

Actors:
ehr Criteria N:

RI.1.1.3.1#01 | SHALL | The system SHALL audit each occurrence when Record Entry content is translated.
RI.1.1.3.1#02 | SHALL | The system SHALL capture identity of the organization where Record Entry content is translated.
RI.1.1.3.1#03 | SHALL | The system SHALL capture identity of the patient who is subject of translated Record Entry content.
RI.1.1.3.1#04 | conditional SHALL | IF a user initiated a Record Entry content translation, THEN the system SHALL capture identity of the user initiating Record Entry content translation.
RI.1.1.3.1#05 | SHALL | The system SHALL capture identity of the system application which translated Record Entry content.
RI.1.1.3.1#06 | SHALL | The system SHALL capture the type of Record Event trigger (i.e., translation).
RI.1.1.3.1#07 | SHALL | The system SHALL capture the date and time Record Entry content is translated.
RI.1.1.3.1#08 | SHOULD | The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is translated.
RI.1.1.3.1#09 | conditional MAY | IF a user initiated a Record Entry translation, THEN the system MAY capture the rationale for translating Record Entry content.
RI.1.1.3.1#10 | SHALL | The system SHALL capture a sequence identifier for translated Record Entry content.
RI.1.1.3.1#11 | SHALL | The system SHALL capture the identifier and version of Translation Tools used for each translated Record Entry.
RI.1.1.3.1#12 | SHALL | The system SHALL capture a reference (e.g., link, pointer) to pre-translation data for each Record Entry translation.