FHIR IG Statistics: Requirements/EHRSFMR2-RI.1.1.5.1

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{
  "resourceType": "Requirements",
  "id": "EHRSFMR2-RI.1.1.5.1",
  "meta": {
    "profile": [
      "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMFunction"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode": "ehr"
    }
  ],
  "url": "http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-RI.1.1.5.1",
  "version": "2.1.1-ballot",
  "name": "RI_1_1_5_1_Evidence_of_Record_Entry_View_Access_Event",
  "title": "RI.1.1.5.1 Evidence of Record Entry View/Access Event (Function)",
  "status": "active",
  "date": "2025-05-13T15:11:00+00:00",
  "publisher": "HL7 International / Electronic Health Records",
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "http://www.hl7.org/Special/committees/ehr"
        }
      ]
    }
  ],
  "description": "Maintain Evidence of Record Entry View/Access Event",
  "jurisdiction": [
    {
      "coding": [
        {
          "system": "http://unstats.un.org/unsd/methods/m49/m49.htm",
          "code": "001",
          "display": "World"
        }
      ]
    }
  ],
  "purpose": "Evidence of Record Entry View/Access Event includes key metadata, ensures health record integrity (and trust) and enables record audit.",
  "statement": [
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-01",
      "label": "RI.1.1.5.1#01",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL audit each occurrence when Record Entry content is viewed/accessed.",
      "derivedFrom": "EHR-LM_R1 14.4"
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-02",
      "label": "RI.1.1.5.1#02",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL capture identity of the organization where Record Entry content is viewed/accessed."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-03",
      "label": "RI.1.1.5.1#03",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL capture identity of the patient who is subject of the viewed/accessed Record Entry content."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-04",
      "label": "RI.1.1.5.1#04",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL capture identity of the user who viewed/accessed Record Entry content."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-05",
      "label": "RI.1.1.5.1#05",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL capture identity of the system application in which Record Entry content is viewed/accessed."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-06",
      "label": "RI.1.1.5.1#06",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL capture the type of Record Event trigger (i.e., view/access)."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-07",
      "label": "RI.1.1.5.1#07",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL capture the date and time Record Entry content is viewed/accessed."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-08",
      "label": "RI.1.1.5.1#08",
      "conformance": [
        "SHOULD"
      ],
      "conditionality": false,
      "requirement": "The system SHOULD capture identity of the location (i.e., network address) where Record Entry content is viewed/accessed."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-09",
      "label": "RI.1.1.5.1#09",
      "conformance": [
        "MAY"
      ],
      "conditionality": false,
      "requirement": "The system MAY capture the rationale for viewing/accessing Record Entry content (e.g., emergency access)."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-10",
      "label": "RI.1.1.5.1#10",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL capture the data, document or other identifier for the viewed/accessed Record Entry content."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-11",
      "label": "RI.1.1.5.1#11",
      "conformance": [
        "MAY"
      ],
      "conditionality": false,
      "requirement": "The system MAY capture whether the data/document viewed/accessed is a primary source record (e.g., patient's record) or an aggregated report (e.g., summary report including multiple patients)."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": true
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-12",
      "label": "RI.1.1.5.1#12",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL capture when a Record Entry content view/access occurrence is known to be a disclosure, according to scope of practice, organizational policy, and/or jurisdictional law."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "EHRSFMR2-RI.1.1.5.1-13",
      "label": "RI.1.1.5.1#13",
      "conformance": [
        "SHOULD"
      ],
      "conditionality": false,
      "requirement": "The system SHOULD capture known and applicable permissions regarding Record Entry content viewed/accessed including confidentiality codes, patient consent authorizations, privacy policy pointers."
    }
  ]
}