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

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## Requirements: RI.1.1.6.1 Evidence of Record Entry Output/Report Event (Function)

Page standards status: Informative

Statement N:

Maintain Evidence of Record Entry Output/Report Event

Description I:

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

Actors:
ehr Criteria N:

RI.1.1.6.1#01 | SHALL | The system SHALL audit each occurrence when an output (e.g., report, screen shot) is generated from Record Entry content.
RI.1.1.6.1#02 | SHALL | The system SHALL capture identity of the organization where output/report is generated from Record Entry content.
RI.1.1.6.1#03 | SHALL | The system SHALL capture identity of the patient who is subject of the Record Entry(ies) populating the output/report generated.
RI.1.1.6.1#04 | SHALL | The system SHALL capture identity of the user who generated the output/report of Record Entry content.
RI.1.1.6.1#05 | SHALL | The system SHALL capture identity of the system application from which the output/report is generated.
RI.1.1.6.1#06 | SHALL | The system SHALL capture the type of Record Event trigger (i.e., output/report).
RI.1.1.6.1#07 | SHALL | The system SHALL capture the date and time the output/report is generated.
RI.1.1.6.1#08 | SHOULD | The system SHOULD capture identity of the location (i.e., network address) where the output/report is generated.
RI.1.1.6.1#09 | MAY | The system MAY capture the rationale for generating the output/report.
RI.1.1.6.1#10 | MAY | The system MAY capture the data, document, or other identifier for the output/report generated.
RI.1.1.6.1#11 | dependent SHALL | The system SHALL capture when a Record Entry content output/report occurrence is known to be a disclosure, according to scope of practice, organizational policy, and/or jurisdictional law.
RI.1.1.6.1#12 | SHOULD | The system SHOULD capture known and applicable permissions regarding Record Entry content output/reported including confidentiality codes, patient consent authorizations, privacy policy pointers.