| Package | hl7.ehrs.ehrsfmr21 |
| Type | Requirements |
| Id | Id |
| FHIR Version | R5 |
| Source | http://hl7.org/ehrs/https://build.fhir.org/ig/mvdzel/ehrsfm-fhir-r5/Requirements-EHRSFMR2.1-RI.1.3.3.html |
| Url | http://hl7.org/ehrs/Requirements/EHRSFMR2.1-RI.1.3.3 |
| Version | 2.1.0 |
| Status | active |
| Date | 2024-11-26T16:30:50+00:00 |
| Name | RI_1_3_3_Manage_Record_Entry_Succession_and_Version_Control |
| Title | RI.1.3.3 Manage Record Entry Succession and Version Control (Function) |
| Experimental | False |
| Realm | uv |
| Authority | hl7 |
| Description | Manage successive Record Entry versions over time. |
| Purpose | 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. |
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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. |
FHIR{
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"id" : "EHRSFMR2.1-RI.1.3.3",
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"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>Manage successive Record Entry versions over time.</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>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.</p>\n<p>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:\nlaboratory 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.</p>\n</div></span>\n \n\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.1.3.3#01</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 manage Record Entries that become new versions when their state changes (e.g., augmented, amended, corrected, etc.).</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.3.3#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 provide the ability to update a Record Entry and save it as a new version.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>RI.1.3.3#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, maintain and render the date, time and user for the original and each updated version 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.1.3.3#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 manage the succession of Record Entries in chronological version order.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n </table>\n</div>"
},
"url" : "http://hl7.org/ehrs/Requirements/EHRSFMR2.1-RI.1.3.3",
"version" : "2.1.0",
"name" : "RI_1_3_3_Manage_Record_Entry_Succession_and_Version_Control",
"title" : "RI.1.3.3 Manage Record Entry Succession and Version Control (Function)",
"status" : "active",
"date" : "2024-11-26T16:30:50+00:00",
"publisher" : "EHR WG",
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"description" : "Manage successive Record Entry versions over time.",
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"coding" : [
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"code" : "001",
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"purpose" : "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.\n\nA 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:\n 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.",
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"label" : "RI.1.3.3#01",
"conformance" : [
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"conditionality" : false,
"requirement" : "The system SHOULD provide the ability to manage Record Entries that become new versions when their state changes (e.g., augmented, amended, corrected, etc.)."
},
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"extension" : [
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"key" : "EHRSFMR2.1-RI.1.3.3-02",
"label" : "RI.1.3.3#02",
"conformance" : [
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"conditionality" : false,
"requirement" : "The system SHALL provide the ability to update a Record Entry and save it as a new version."
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"extension" : [
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"valueBoolean" : false
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"key" : "EHRSFMR2.1-RI.1.3.3-03",
"label" : "RI.1.3.3#03",
"conformance" : [
"SHALL"
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"conditionality" : false,
"requirement" : "The system SHALL capture, maintain and render the date, time and user for the original and each updated version of the Record Entry."
},
{
"extension" : [
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"key" : "EHRSFMR2.1-RI.1.3.3-04",
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"conformance" : [
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"conditionality" : false,
"requirement" : "The system SHALL manage the succession of Record Entries in chronological version order."
}
]
}
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