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

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

: RI.1.3 Record States (Header) - XML Representation

Page standards status: Informative

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<Requirements xmlns="http://hl7.org/fhir">
  <id value="EHRSFMR2-RI.1.3"/>
  <meta>
    <profile
             value="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMHeader"/>
  </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 Record States</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>Record Entries may reside in various states that must be managed. An important underlying principle for managing record states is the need to retain Record Entries that have been viewed for patient care purposes even if the Entry has not been completed or attested. This principle has important legal impact because it provides an account of what the provider viewed and relied on for clinical decision-making. For example, if Record Entry content was available in pending state and a clinician used the information to make decisions, it is important to retain the pending version even after the final version was available. Determining if Record Entry content was used for patient care may be challenging. Access logs could provide a mechanism to determine if the information was used.</p>
</div></span>
    

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

    
    <table id="statements" class="grid dict">
        
    </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"/>
  <version value="2.1.1-ballot"/>
  <name value="RI_1_3_Record_States"/>
  <title value="RI.1.3 Record States (Header)"/>
  <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 Record States"/>
  <jurisdiction>
    <coding>
      <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
      <code value="001"/>
      <display value="World"/>
    </coding>
  </jurisdiction>
  <purpose
           value="Record Entries may reside in various states that must be managed. An important underlying principle for managing record states is the need to retain Record Entries that have been viewed for patient care purposes even if the Entry has not been completed or attested. This principle has important legal impact because it provides an account of what the provider viewed and relied on for clinical decision-making. For example, if Record Entry content was available in pending state and a clinician used the information to make decisions, it is important to retain the pending version even after the final version was available. Determining if Record Entry content was used for patient care may be challenging. Access logs could provide a mechanism to determine if the information was used."/>
</Requirements>