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FHIR IG Statistics: Requirements/EHRSFMR2-RI.1.1.1.1

Packagehl7.ehrs.uv.ehrsfmr2
TypeRequirements
IdEHRSFMR2-RI.1.1.1.1
FHIR VersionR5
Sourcehttp://hl7.org/ehrs/uv/ehrsfmr2/https://build.fhir.org/ig/mvdzel/ehrsfm-fhir-r5/Requirements-EHRSFMR2-RI.1.1.1.1.html
URLhttp://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-RI.1.1.1.1
Version2.1.1-ballot
Statusactive
Date2025-05-13T15:11:00+00:00
NameRI_1_1_1_1_Evidence_of_Record_Entry_Originate_Retain_Event
TitleRI.1.1.1.1 Evidence of Record Entry Originate/Retain Event (Function)
Realmuv
Authorityhl7
DescriptionMaintain Evidence of Record Entry Originate/Retain Event
PurposeEvidence of Record Entry Originate/Retain Event includes key metadata, ensures health record integrity (and trust) and enables record audit.

Resources that use this resource

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Resources that this resource uses

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Narrative

Note: links and images are rebased to the (stated) source

Statement N:

Maintain Evidence of Record Entry Originate/Retain Event

 Description I:

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

 Actors:
ehr Criteria N:
RI.1.1.1.1#01 SHALL

The system SHALL audit each occurrence when a Record Entry is originated and retained.
RI.1.1.1.1#02 SHALL

The system SHALL capture identity of the organization where Record Entry content is originated.
RI.1.1.1.1#03 SHALL

The system SHALL capture identity of the patient who is subject of Record Entry content.
RI.1.1.1.1#04 SHALL

The system SHALL capture identity of the individual(s) who performed the Action documented in Record Entry content.
RI.1.1.1.1#05 SHALL

The system SHALL capture identity of the user who entered/authored Record Entry content.
RI.1.1.1.1#06 SHALL

The system SHALL capture identity of the system application which originated Record Entry content.
RI.1.1.1.1#07 conditional SHALL

IF the source of Record Entry content is a device, THEN the system SHALL capture identity of the device.
RI.1.1.1.1#08 SHALL

The system SHALL capture the Action as evidenced by Record Entry content.
RI.1.1.1.1#09 SHALL

The system SHALL capture the type of Record Event trigger (i.e., originate/retain).
RI.1.1.1.1#10 SHALL

The system SHALL capture the date and time of Action occurrence as evidenced by Record Entry content.
RI.1.1.1.1#11 SHALL

The system SHALL capture the date and time Record Entry content is originated.
RI.1.1.1.1#12 MAY

The system MAY capture the duration of the Action evidenced by Record Entry content.
RI.1.1.1.1#13 MAY

The system MAY capture the physical location of the Action evidenced by Record Entry content.
RI.1.1.1.1#14 SHOULD

The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is originated.
RI.1.1.1.1#15 MAY

The system MAY capture the rationale for the Action evidenced by Record Entry content.
RI.1.1.1.1#16 MAY

The system MAY capture the rationale for originating Record Entry content.
RI.1.1.1.1#17 conditional SHOULD

IF Record Entry content includes templates (boilerplate information) or copied (duplicated) information, THEN the system SHOULD capture the source of such content.

Source

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  "meta": {
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    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
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  ],
  "url": "http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-RI.1.1.1.1",
  "version": "2.1.1-ballot",
  "name": "RI_1_1_1_1_Evidence_of_Record_Entry_Originate_Retain_Event",
  "title": "RI.1.1.1.1 Evidence of Record Entry Originate/Retain Event (Function)",
  "status": "active",
  "date": "2025-05-13T15:11:00+00:00",
  "publisher": "HL7 International / Electronic Health Records",
  "contact": [
    {
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        {
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          "value": "http://www.hl7.org/Special/committees/ehr"
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  ],
  "description": "Maintain Evidence of Record Entry Originate/Retain Event",
  "jurisdiction": [
    {
      "coding": [
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          "code": "001",
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        }
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  ],
  "purpose": "Evidence of Record Entry Originate/Retain Event includes key metadata, ensures health record integrity (and trust) and enables record audit.",
  "statement": [
    {
      "extension": [
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          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.1.1-01",
      "label": "RI.1.1.1.1#01",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL audit each occurrence when a Record Entry is originated and retained.",
      "derivedFrom": "EHR-LM_R1 14.1"
    },
    {
      "extension": [
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          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.1.1-02",
      "label": "RI.1.1.1.1#02",
      "conformance": [
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      ],
      "conditionality": false,
      "requirement": "The system SHALL capture identity of the organization where Record Entry content is originated.",
      "derivedFrom": "EHR-LM_R1 14.1"
    },
    {
      "extension": [
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          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.1.1-03",
      "label": "RI.1.1.1.1#03",
      "conformance": [
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      ],
      "conditionality": false,
      "requirement": "The system SHALL capture identity of the patient who is subject of Record Entry content.",
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          "valueBoolean": false
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      ],
      "key": "EHRSFMR2-RI.1.1.1.1-04",
      "label": "RI.1.1.1.1#04",
      "conformance": [
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      ],
      "conditionality": false,
      "requirement": "The system SHALL capture identity of the individual(s) who performed the Action documented in Record Entry content.",
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      ],
      "key": "EHRSFMR2-RI.1.1.1.1-05",
      "label": "RI.1.1.1.1#05",
      "conformance": [
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      ],
      "conditionality": false,
      "requirement": "The system SHALL capture identity of the user who entered/authored Record Entry content.",
      "derivedFrom": "EHR-LM_R1 14.1"
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.1.1-06",
      "label": "RI.1.1.1.1#06",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL capture identity of the system application which originated Record Entry content."
    },
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      "extension": [
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          "valueBoolean": false
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      ],
      "key": "EHRSFMR2-RI.1.1.1.1-07",
      "label": "RI.1.1.1.1#07",
      "conformance": [
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      ],
      "conditionality": true,
      "requirement": "IF the source of Record Entry content is a device, THEN the system SHALL capture identity of the device.",
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      "key": "EHRSFMR2-RI.1.1.1.1-08",
      "label": "RI.1.1.1.1#08",
      "conformance": [
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      ],
      "conditionality": false,
      "requirement": "The system SHALL capture the Action as evidenced by Record Entry content."
    },
    {
      "extension": [
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          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
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      ],
      "key": "EHRSFMR2-RI.1.1.1.1-09",
      "label": "RI.1.1.1.1#09",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL capture the type of Record Event trigger (i.e., originate/retain)."
    },
    {
      "extension": [
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          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.1.1-10",
      "label": "RI.1.1.1.1#10",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL capture the date and time of Action occurrence as evidenced by Record Entry content.",
      "derivedFrom": "EHR-LM_R1 14.1"
    },
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          "valueBoolean": false
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      ],
      "key": "EHRSFMR2-RI.1.1.1.1-11",
      "label": "RI.1.1.1.1#11",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL capture the date and time Record Entry content is originated.",
      "derivedFrom": "EHR-LM_R1 14.1"
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.1.1-12",
      "label": "RI.1.1.1.1#12",
      "conformance": [
        "MAY"
      ],
      "conditionality": false,
      "requirement": "The system MAY capture the duration of the Action evidenced by Record Entry content."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.1.1-13",
      "label": "RI.1.1.1.1#13",
      "conformance": [
        "MAY"
      ],
      "conditionality": false,
      "requirement": "The system MAY capture the physical location of the Action evidenced by Record Entry content.",
      "derivedFrom": "EHR-LM_R1 14.1"
    },
    {
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        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.1.1-14",
      "label": "RI.1.1.1.1#14",
      "conformance": [
        "SHOULD"
      ],
      "conditionality": false,
      "requirement": "The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is originated.",
      "derivedFrom": "EHR-LM_R1 14.1"
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.1.1-15",
      "label": "RI.1.1.1.1#15",
      "conformance": [
        "MAY"
      ],
      "conditionality": false,
      "requirement": "The system MAY capture the rationale for the Action evidenced by Record Entry content."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.1.1-16",
      "label": "RI.1.1.1.1#16",
      "conformance": [
        "MAY"
      ],
      "conditionality": false,
      "requirement": "The system MAY capture the rationale for originating Record Entry content."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.1.1-17",
      "label": "RI.1.1.1.1#17",
      "conformance": [
        "SHOULD"
      ],
      "conditionality": true,
      "requirement": "IF Record Entry content includes templates (boilerplate information) or copied (duplicated) information, THEN the system SHOULD capture the source of such content."
    }
  ]
}