HL7 Electronic Health Record System Functional Model, Release 2.1.1
2.1.1-ballot - Normative Ballot
This page is part of the HL7 Electronic Health Record System Functional Model, Release 2.1.1 (v2.1.1-ballot: Normative 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. No current official version has been published yet. For a full list of available versions, see the Directory of published versions
| Page standards status: Informative |
Manage successive Record Entry versions over time.
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.
| RI.1.3.3#01 | SHOULD |
The system SHOULD provide the ability to manage Record Entries that become new versions when their state changes (e.g., augmented, amended, corrected, etc.). |
| RI.1.3.3#02 | SHALL |
The system SHALL provide the ability to update a Record Entry and save it as a new version. |
| RI.1.3.3#03 | SHALL |
The system SHALL capture, maintain and render the date, time and user for the original and each updated version of the Record Entry. |
| RI.1.3.3#04 | SHALL |
The system SHALL manage the succession of Record Entries in chronological version order. |