HL7 Personal Health Record System Functional Model, Release 2
2.0.1-ballot - Normative Ballot

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## : RI.1.1.1 Originate/Retain Record Lifecycle Event (Function) - JSON Representation

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    {
      "resourceType" : "Requirements",
      "id" : "PHRSFMR2-RI.1.1.1",
      "meta" : {
        "profile" : [
          🔗 "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/FMFunction"
        ]
      },
      "text" : {
        "status" : "extensions",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n    <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>Originate and Retain Record Entry (1 instance)</p>\n</div></span>\n\n    \n    <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>Occurs when an agent causes the system to: a) initiate capture of potential record content, and b) incorporate that content into the storage considered a permanent part of the health record.</p>\n<p>Reference: ISO 21089-2018, Section 15.1.</p>\n</div></span>\n    \n\n    \n    <span id=\"actors\"><b>Actors:</b><br/> ehr</span>\n    \n\n    \n    <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>\n    \n    <table id=\"statements\" class=\"grid dict\">\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>RI.1.1.1#01</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHALL provide the ability to capture (originate) a Record Entry instance corresponding to an Action instance and context.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>RI.1.1.1#02</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHALL capture a unique instance identifier for each Record Entry.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>RI.1.1.1#03</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHALL capture the signature event (e.g., digital signature) of the origination entry Author, binding signature to Record Entry content.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>RI.1.1.1#04</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHALL provide the ability to capture both structured and unstructured content in Record Entries.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>RI.1.1.1#05</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHALL provide the ability to capture Record Entries from information recorded during system downtime.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>RI.1.1.1#06</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD provide the ability to integrate Record Entries from Information recorded during system downtime.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>RI.1.1.1#07</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHALL provide the ability to capture the date/time an Action was taken or data was collected if different than date/time of the Record Entry.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>RI.1.1.1#08</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD capture metadata that identifies the source of non-originated Record Entry (e.g., templated, copied, duplicated, or boilerplate information).</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>RI.1.1.1#09</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>MAY</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system MAY provide the ability to tag unstructured Record Entry content to organize it according to need, for example, in a time-related fashion or by application-specific groups (such as photographs, handwritten notes, or auditory sounds), or by order of relative importance.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>RI.1.1.1#10</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>MAY</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system MAY capture and maintain a Record Entry encoded as a standards-based data object (e.g., HL7 Continuity of Care, other HL7 CDA R2 Document, ISO 13606 artifact).</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>RI.1.1.1#11</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>MAY</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system MAY capture and maintain a standards-based data object to mirror (be duplicate and synchronous with) internal Record Entry representation.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n    </table>\n</div>"
      },
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
          "valueCode" : "ehr"
        }
      ],
      "url" : "http://hl7.org/ehrs/uv/phrsfmr2/Requirements/PHRSFMR2-RI.1.1.1",
      "version" : "2.0.1-ballot",
      "name" : "RI_1_1_1_Originate_Retain_Record_Lifecycle_Event",
      "title" : "RI.1.1.1 Originate/Retain Record Lifecycle Event (Function)",
      "status" : "active",
      "date" : "2025-04-04T11:42:51+11:00",
      "publisher" : "EHR WG",
      "contact" : [
        {
          "telecom" : [
            {
              "system" : "url",
              "value" : "http://www.hl7.org/Special/committees/ehr"
            }
          ]
        }
      ],
      "description" : "Originate and Retain Record Entry (1 instance)",
      "purpose" : "Occurs when an agent causes the system to: a) initiate capture of potential record content, and b) incorporate that content into the storage considered a permanent part of the health record. \r\n\r\nReference: ISO 21089-2018, Section 15.1.",
      "statement" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-RI.1.1.1-01",
          "label" : "RI.1.1.1#01",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : false,
          "requirement" : "The system SHALL provide the ability to capture (originate) a Record Entry instance corresponding to an Action instance and context."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-RI.1.1.1-02",
          "label" : "RI.1.1.1#02",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : false,
          "requirement" : "The system SHALL capture a unique instance identifier for each Record Entry."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-RI.1.1.1-03",
          "label" : "RI.1.1.1#03",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : false,
          "requirement" : "The system SHALL capture the signature event (e.g., digital signature) of the origination entry Author, binding signature to Record Entry content."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-RI.1.1.1-04",
          "label" : "RI.1.1.1#04",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : false,
          "requirement" : "The system SHALL provide the ability to capture both structured and unstructured content in Record Entries."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-RI.1.1.1-05",
          "label" : "RI.1.1.1#05",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : false,
          "requirement" : "The system SHALL provide the ability to capture Record Entries from information recorded during system downtime."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-RI.1.1.1-06",
          "label" : "RI.1.1.1#06",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD provide the ability to integrate Record Entries from Information recorded during system downtime."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-RI.1.1.1-07",
          "label" : "RI.1.1.1#07",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : false,
          "requirement" : "The system SHALL provide the ability to capture the date/time an Action was taken or data was collected if different than date/time of the Record Entry."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-RI.1.1.1-08",
          "label" : "RI.1.1.1#08",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD capture metadata that identifies the source of non-originated Record Entry (e.g., templated, copied, duplicated, or boilerplate information)."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-RI.1.1.1-09",
          "label" : "RI.1.1.1#09",
          "conformance" : [
            "MAY"
          ],
          "conditionality" : false,
          "requirement" : "The system MAY provide the ability to tag unstructured Record Entry content to organize it according to need, for example, in a time-related fashion or by application-specific groups (such as photographs, handwritten notes, or auditory sounds), or by order of relative importance."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-RI.1.1.1-10",
          "label" : "RI.1.1.1#10",
          "conformance" : [
            "MAY"
          ],
          "conditionality" : false,
          "requirement" : "The system MAY capture and maintain a Record Entry encoded as a standards-based data object (e.g., HL7 Continuity of Care, other HL7 CDA R2 Document, ISO 13606 artifact)."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-RI.1.1.1-11",
          "label" : "RI.1.1.1#11",
          "conformance" : [
            "MAY"
          ],
          "conditionality" : false,
          "requirement" : "The system MAY capture and maintain a standards-based data object to mirror (be duplicate and synchronous with) internal Record Entry representation."
        }
      ]
    }