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

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## : RI.1.3.3 Manage Record Entry Succession and Version Control (Function) - XML Representation

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    <Requirements xmlns="http://hl7.org/fhir">
      <id value="EHRSFMR2-RI.1.3.3"/>
      <meta>
        <profile
                 value="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMFunction"/>
      </meta>
      <text>
        <status value="extensions"/>
        <div xmlns="http://www.w3.org/1999/xhtml">
        <span id="description"><b>Statement <a href="https://hl7.org/fhir/versions.html#std-process" title="Normative Content" class="normative-flag">N</a>:</b> <div><p>Manage successive Record Entry versions over time.</p>
    </div></span>

        <span id="purpose"><b>Description <a href="https://hl7.org/fhir/versions.html#std-process" title="Informative Content" class="informative-flag">I</a>:</b> <div><p>The system must have a mechanism to handle versions and succession of Record Entries (such as a preliminary and final laboratory reports, amended or corrected documents). Versioning and succession management is based on Record Entry content, and/or status change over time.</p>
    <p>A version may be one of:1) A completed and attested Record Entry; 2) A Record Entry completed and attested which has been modified one or more times3) A Record Entry that has been viewed for clinical decision-making purposes by an individual other than the author4) A Record Entry that has been captured in an incomplete state per organization business rules and updated over time (i.e., a preliminary laboratory test). 5) A Record Entry that electively, according to the author, must be preserved in the current state at a given point in time (i.e., History and Physical). Certain types of Record Entries are typically handled in versions, for example:
    laboratory results (preliminary and final)- Dictated reports- Work ups (over course of days)The prior version of Record Entries should be retained for the legally prescribed timeframe as defined by scope of practice, organizational policy, and jurisdictional law.</p>
    </div></span>

        <span id="actors"><b>Actors:</b><br/> ehr</span>

        <span id="requirements"><b>Criteria <a href="https://hl7.org/fhir/versions.html#std-process" title="Normative Content" class="normative-flag">N</a>:</b></span>

        <table id="statements" class="grid dict">

            <tr>
                <td style="padding-left: 4px;">

                    <span>RI.1.3.3#01</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHOULD</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHOULD provide the ability to manage Record Entries that become new versions when their state changes (e.g., augmented, amended, corrected, etc.).</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>RI.1.3.3#02</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHALL</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHALL provide the ability to update a Record Entry and save it as a new version.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>RI.1.3.3#03</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHALL</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHALL capture, maintain and render the date, time and user for the original and each updated version of the Record Entry.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>RI.1.3.3#04</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHALL</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHALL manage the succession of Record Entries in chronological version order.</p>
    </div></span>

                </td>
            </tr>

        </table>
    </div>
      </text>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
        <valueCode value="ehr"/>
      </extension>
      <url
           value="http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-RI.1.3.3"/>
      <version value="2.1.1-ballot"/>
      <name value="RI_1_3_3_Manage_Record_Entry_Succession_and_Version_Control"/>
      <title
             value="RI.1.3.3 Manage Record Entry Succession and Version Control (Function)"/>
      <status value="active"/>
      <date value="2025-04-04T11:04:36+11:00"/>
      <publisher value="HL7 International / Electronic Health Records"/>
      <contact>
        <telecom>
          <system value="url"/>
          <value value="http://www.hl7.org/Special/committees/ehr"/>
        </telecom>
      </contact>
      <description value="Manage successive Record Entry versions over time."/>
      <jurisdiction>
        <coding>
          <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
          <code value="001"/>
          <display value="World"/>
        </coding>
      </jurisdiction>
      <purpose
               value="The system must have a mechanism to handle versions and succession of Record Entries (such as a preliminary and final laboratory reports, amended or corrected documents). Versioning and succession management is based on Record Entry content, and/or status change over time.

    A version may be one of:1) A completed and attested Record Entry; 2) A Record Entry completed and attested which has been modified one or more times3) A Record Entry that has been viewed for clinical decision-making purposes by an individual other than the author4) A Record Entry that has been captured in an incomplete state per organization business rules and updated over time (i.e., a preliminary laboratory test). 5) A Record Entry that electively, according to the author, must be preserved in the current state at a given point in time (i.e., History and Physical). Certain types of Record Entries are typically handled in versions, for example:
            laboratory results (preliminary and final)- Dictated reports- Work ups (over course of days)The prior version of Record Entries should be retained for the legally prescribed timeframe as defined by scope of practice, organizational policy, and jurisdictional law."/>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-RI.1.3.3-01"/>
        <label value="RI.1.3.3#01"/>
        <conformance value="SHOULD"/>
        <conditionality value="false"/>
        <requirement
                     value="The system SHOULD provide the ability to manage Record Entries that become new versions when their state changes (e.g., augmented, amended, corrected, etc.)."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-RI.1.3.3-02"/>
        <label value="RI.1.3.3#02"/>
        <conformance value="SHALL"/>
        <conditionality value="false"/>
        <requirement
                     value="The system SHALL provide the ability to update a Record Entry and save it as a new version."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-RI.1.3.3-03"/>
        <label value="RI.1.3.3#03"/>
        <conformance value="SHALL"/>
        <conditionality value="false"/>
        <requirement
                     value="The system SHALL capture, maintain and render the date, time and user for the original and each updated version of the Record Entry."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-RI.1.3.3-04"/>
        <label value="RI.1.3.3#04"/>
        <conformance value="SHALL"/>
        <conditionality value="false"/>
        <requirement
                     value="The system SHALL manage the succession of Record Entries in chronological version order."/>
      </statement>
    </Requirements>