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

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## Requirements: RI.1.1.5.1 Evidence of Record Entry View/Access Event (Function)

Page standards status: Informative

Statement N:

Maintain Evidence of Record Entry View/Access Event

Description I:

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

Actors:
ehr Criteria N:

RI.1.1.5.1#01 | SHALL | The system SHALL audit each occurrence when Record Entry content is viewed/accessed.
RI.1.1.5.1#02 | SHALL | The system SHALL capture identity of the organization where Record Entry content is viewed/accessed.
RI.1.1.5.1#03 | SHALL | The system SHALL capture identity of the patient who is subject of the viewed/accessed Record Entry content.
RI.1.1.5.1#04 | SHALL | The system SHALL capture identity of the user who viewed/accessed Record Entry content.
RI.1.1.5.1#05 | SHALL | The system SHALL capture identity of the system application in which Record Entry content is viewed/accessed.
RI.1.1.5.1#06 | SHALL | The system SHALL capture the type of Record Event trigger (i.e., view/access).
RI.1.1.5.1#07 | SHALL | The system SHALL capture the date and time Record Entry content is viewed/accessed.
RI.1.1.5.1#08 | SHOULD | The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is viewed/accessed.
RI.1.1.5.1#09 | MAY | The system MAY capture the rationale for viewing/accessing Record Entry content (e.g., emergency access).
RI.1.1.5.1#10 | SHALL | The system SHALL capture the data, document or other identifier for the viewed/accessed Record Entry content.
RI.1.1.5.1#11 | MAY | The system MAY capture whether the data/document viewed/accessed is a primary source record (e.g., patient's record) or an aggregated report (e.g., summary report including multiple patients).
RI.1.1.5.1#12 | dependent SHALL | The system SHALL capture when a Record Entry content view/access occurrence is known to be a disclosure, according to scope of practice, organizational policy, and/or jurisdictional law.
RI.1.1.5.1#13 | SHOULD | The system SHOULD capture known and applicable permissions regarding Record Entry content viewed/accessed including confidentiality codes, patient consent authorizations, privacy policy pointers.