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					                             Statement,
                                                               R2 Target
IN Ref.        Function Name Description                                             IN.2 Functions/Criteria from 1st Pass Review (R1
IN.2                          Statement: Manage EHR 0
           H Health Record Information and Management   information across EHR-S applications by ensuring that clinical information enter
IN.2.1                        Statement: Retain, ensure 0
           F Data Retention, Availability and Destruction availability, and destroy health record information according to scope of practice
IN.2.1     C                                   IN.1.7      1 RI.1.2.1, CC#2,5,6 1. The system SHALL provide the ability to store and r
IN.2.1     C                                               2 RI.1.1.7, CC#1,2        2. The system SHALL provide the ability to retain inbo
                                                             RI.1.2.1, CC#1,2,3,4
IN.2.1     C                                               3 RI.1.1.7, CC#1,2        3. The system SHALL retain the content of inbound da
                                                             RI.1.2.1, CC#1,2,3,4
IN.2.1     C                                               4 RI.1.1.1, CC#1          4. The system SHOULD provide the ability to retrieve b
                                                             RI.1.2.1, CC#8-9
IN.2.1     C                                               5 RI.1.1.1, CC#1          The system SHOULD provide the ability to restore both
                                                             RI.1.2.1, CC#8-9
IN.2.1     C                                               6 RI.1.2.1, CC#10         5. The system SHOULD provide the ability to retrieve a
IN.2.1     C                                               7 RI.1.2.1, CC#11         6. The system MAY (automatically or manually) provid
IN.2.1     C                                               8 RI.1.2.1, CC#12         IF the system provides the ability to tag specific EHR d
IN.2.1     C                                               9 RI.1.2.1, CC#13         IF the system provides the ability to tag specific EHR d
IN.2.1     C                                             10 RI.1.2.1, CC#14          IF the system provides the ability to tag specific EHR d
IN.2.1     C                                             11 RI.1.2.1, CC#15          The system MAY provide the ability to undelete EHR d
IN.2.1     C                                             12 ? Purge = secure         7. The system MAY provide the ability to purge EHR d
                                                             delete
IN.2.1     C                                             13 RI.1.2.1, CC#16          8. The system MAY transmit record destruction date in
IN.2.1     C                                             14 RI.1.1.1, CC#7           The system SHALL provide the ability to capture inform
IN.2.1     C                                             15 RI.1.1.1, CC#8           The system SHOULD provide the ability to integrate in
IN.2.1     C                                             16 RI.1.2.1, CC#17          The system SHOULD manage health care information
IN.2.1     C                                             17                          IF the PHR-S provides the ability to identify specific PH
                                                             NOT EHRS Function
IN.2.1     C                                              18 Consents?         If the EHR-S receives information from a PHR-S that t
IN.2.1     C                                              19                   The PHR-S MAY permit the PHR Account Holder to de
                                                             NOT EHRS Function
IN.2.1     C                                              20RI.1.1.15, CC#3        The system SHOULD provide the ability to re-activate
IN.2.1     C                                              21RI.1.1.13-14           The system SHALL provide the ability to tag any type
IN.2.1     C                                              22TI.2.1.1.14.13         The system SHALL provide the ability to capture the re
IN.2.1     C                                              23RI.1.1.13, CC#2        The system SHALL provide the ability to tag any inacti
                                                            RI.1.1.14, CC#2
IN.2.1.1   F                   Statement: EHR systems 0
               Record Preservation                      must support a need to preserve data from normal destruction practices. Descrip
IN.2.1.1   C                                              1 RI.1.2.2, CC#1         The system SHOULD provide the ability to secure data
IN.2.1.1   C                                              2 RI.1.2.2, CC#2         The system SHALL provide the ability to preserve reco
IN.2.1.1   C                                              3 RI.1.2.2, CC#3         The system SHOULD provide the ability to identify the
IN.2.1.1   C                                              4 RI.1.2.2, CC#5         The system MAY map medical record elements to the
                                                            RI.1.2.1, CC#9
IN.2.1.1   C                                              5 RI.1.2.2, CC#4         The system SHOULD provide the ability to generate a
IN.2.2     F                   Statement: Provide audit capabilities for system access and usage indicating the author, the modification (
               Auditable Records                        0
IN.2.2     C                                              1 Move to TI.2.1.2-3     1. The system SHALL provide audit capabilities for rec
IN.2.2     C                                              2 Move to TI.2.3         2. The system SHALL conform to function TI.1.1 (Entit
                                                            Audit Log Access
IN.2.2     C                                              3 TI.2.1.1.1             3. The system SHALL provide audit capabilities indica
IN.2.2     C                                              4 TI.2.1.1.2             4. The system SHALL provide audit capabilities indica
IN.2.2     C                                              5 TI.2.1.1.6             5. The system SHALL provide audit capabilities indica
                                                            TI.2.1.1.11
IN.2.2     C                                              6 TI.2.1.1.6-7           6. The system SHALL provide audit capabilities indica
IN.2.2   C    7   TI.2.1.1.5               7. The system SHALL provide audit capabilities indica
IN.2.2   C    8   TI.2.1.1.13              8. The system SHALL provide audit capabilities indica
IN.2.2   C    9   TI.2.1.1.1-2             9. The system SHALL provide audit capabilities indica
IN.2.2   C   10   TI.2.1.1.5               10. The system SHALL provide audit capabilities indic
                  TI.2.1.1.5.4
IN.2.2   C   11   RI.1.1.2, CC#2           11. The system SHALL provide audit capabilities indic
                  Also TI.2
IN.2.2   C   12   Move to TI.2.1.2-3       12. The system SHALL provide audit capabilities to ca
IN.2.2   C   13   Move to TI.2.2           13. The system SHALL conform to function TI.1.3 (Ent
IN.2.2   C   14   Move to TI.2.2           The system SHALL conform to function TI.1.3 (Entity A
IN.2.2   C   15   Move to TI.2.2           The system SHALL conform to function TI.1.3 (Entity A
IN.2.2   C   16   Move to TI.2.3           14. The system SHALL provide the ability to generate
IN.2.2   C   17   RI.1.1.5, CC#2           15. The system SHALL provide the ability to view chan
IN.2.2   C   18   RI.1.1.5, CC#3           The system SHOULD provide the ability to view chang
IN.2.2   C   19   Move to TI.2.1.3         16. The system SHOULD provide the ability to record s
IN.2.2   C   20   Move to TI.2.1.3         17. The system SHOULD provide the ability to record s
IN.2.2   C   21                            18. The system SHALL provide the ability to record ch
IN.2.2   C   22 RI.1.1.1, CC#9             The system SHALL provide the ability to record date a
IN.2.2   C   23 Move to TI.2.1.3           19. The system SHOULD provide the ability to record s
                Covered in TI.8?
IN.2.2   C   24 TI.2.1.1.12                20. The system SHOULD provide the ability to record s
                Covered in RI.3?
IN.2.2   C   25 TI.2.1.1.15                21. The system SHALL provide the ability to record sy
                Covered in RI.3?
IN.2.2   C   26 Move to TI.2.1.2-3         22. The system SHALL provide the ability to record sy
IN.2.2   C   27 Move to TI.2.1.2-3         23. The system SHALL provide the ability to record sy
IN.2.2   C   28 TI.2.1 CC#4                24. The system SHALL utilize standardized time keepi
IN.2.2   C   29 Move to TI.2.2             25. The system SHALL provide the ability to record an
                Log Management
IN.2.2   C   30 Move to TI.2.1.3           . . . audit event in the case of detection of corrupt or di
IN.2.2   C   31 Move to TI.2.1.4           The system SHALL provide the capability to track all c
                Clinical Audit
                Triggers
IN.2.2   C   32 Move to TI.2.1.4           The system SHALL provide the capability to track all a
                Clinical Audit
                Triggers
IN.2.2   C   33 RI.1.1.5, CC#2             The system MAY provide the ability to maintain the con
IN.2.2   C   34 RI.1.1.5, CC#2             The system MAY provide the ability to maintain the con
IN.2.2   C   35 RI.1.1.5, CC#2             The system MAY provide the ability to maintain the con
IN.2.2   C   36 Move to TI.2.1.4           System functionality SHOULD track when decision sup
                Clinical Audit
                Triggers
IN.2.2   C   37                            The system SHALL prevent edits to and removal of a p
                Move to TI.2.2
                Audit Log Indelibility

IN.2.2   C   38                            The system SHALL prevent edits to and removal of pre
                  Move to TI.2.2
                  Audit Log Indelibility

IN.2.2   C   39 Move to TI.2.2             The system SHOULD provide the ability to annotate or
                Log Management
IN.2.2   C   40 Move to TI.2.1.2           The system SHALL provide the ability to enter the reas
IN.2.2     C                                             41 RI.1.1.7, CC#1,2        IF the system imports or transmits data sets, THEN the
IN.2.2     C                                             42 Move to TI.2.2          The system SHOULD provide the ability to securely sto
                                                            Log Management
IN.2.2     C                                             43 Move to TI.2.2          The system SHALL provide the ability to log access to
                                                            Log Management
IN.2.2     C                                             44 TI.2.1, CC#5            The system SHALL provide the ability to enable or disa
IN.2.2     C                                             45 TI.2.1, CC#6            The system MAY support logging to a common audit e
IN.2.2     C                                             46 Move to TI.2.1.2        The system MAY be able to detect security-relevant ev
IN.2.2     C                                             47 TI.2.1 Metadata         The system SHALL record within each audit record the
IN.2.2     C                                             48                         The system SHALL provide the capability to generate
                                                            Move to TI.2.3
                                                            Audit Log Reporting

IN.2.2     C                                             49                         The system SHOULD export audit record time stamps
                                                              Move to TI.2.3
                                                              Audit Log Reporting

IN.2.2     C                                             50 TI.2.1 CC#4             The system SHALL ensure audit date/time stamps are
IN.2.2     C                                             51                         The system SHALL provide audit capabilities indicating
                                                            TI.2.1.1
                                                            create = MAY
                                                            change = SHOULD
                                                            delete = MAY

IN.2.2.1                      Statement: Metadata (at the point of
           F Point of Record Minimum Metadata Set and Retentionpatient record capture) includes information about the context of reco
                                                       0
IN.2.2.1   C                                             1 RI.1.1.1, CC#10        The system SHOULD capture metadata that identifies
IN.2.2.1   C                                             2 TI.2.1.1.1             The system SHALL retain a minimum metadata set co
IN.2.2.1   C                                             3 RI.1.1.6, CC#1-3       The system SHOULD include the minimum metadata s
                                                           TI.2.1.1.6
IN.2.3                                                 0
           F Synchronization Statement: Maintain synchronization involving: - Interaction with entity directories;- Linkage of received dat
IN.2.3     C                                             1 Move to RI.1.5         1. The system SHALL conform to function IN.5.1 (Inter
IN.2.3     C                                             2 Move to RI.1.5         2. The system SHOULD conform to function IN.3 (Reg
IN.2.3     C                                             3 Move to RI.1.5         3. The system SHOULD provide the ability to link entit
IN.2.3     C                                             4 Move to RI.1.5         4. The system SHOULD store the location of each kno
IN.2.3     C                                             5 Move to RI.1.5         The system SHALL provide the ability to manage and
IN.2.4                        Statement: Manage data 0
           F Extraction of Health Record Information extraction in accordance with analysis and reporting requirements. The extracted
IN.2.4     C                                             1 RI.1.1.11
                                               S.2.2¶IN.4.4¶IN.5.1                1. The system SHALL provide the ability to extract hea
IN.2.4     C                                             2 RI.1.1.6, CC #9        2. IF the extracted data is to be electronically exchang
IN.2.4     C                                             3 RI.1.1.8               3. The system SHALL provide the ability to de-identify
                                                           RI.1.1.11, CC#2
                                                           RI.1.1.6, CC#11
IN.2.4     C                                             4 RI.1.1.11              4. The system SHALL conform to function IN.5.1 (Inter
                                                           RI.1.1.6, CC#2
IN.2.4     C                                             5 RI.1.1.11, CC#5        5. The system SHOULD provide the ability to perform
IN.2.4     C                                             6 RI.1.1.11, CC#6        6. The system SHOULD provide the ability to perform
IN.2.4     C                                             7 RI.1.1.11, CC#7        The system SHOULD provide the ability to perform ext
IN.2.4     C                                             8 RI.1.1.11, CC#8        7. The system SHALL provide the ability to extract data
IN.2.4     C                                             9 RI.1.1.11, CC#8        8. The system SHOULD provide the ability to extract d
IN.2.4     C                                            10 RI.1.1.11, CC#8        9. The system SHOULD provide the ability to extract d
IN.2.4     C                                            11 RI.1.1.11, CC#8        10. The system SHALL provide the ability to extract da
IN.2.4     C                                            12 RI.1.1.11, CC#8        11. The system SHOULD provide the ability to extract
IN.2.4     C                                            13 RI.1.1.11, CC#9        The system SHOULD provide the ability to extract hea
IN.2.4     C                                            14 RI.1.1.11, CC#10       The system SHOULD provide the ability to specify par
IN.2.4       C                                             15                        IF the system exports health record content to multiple
                                                                RI.1.1.6, CC#12-13
IN.2.4.1                       Statement: Automated search and retrieval technology is necessary and valuable in identifying and retrievi
             F Search and Retrieve                    0
IN.2.4.1     C                                           1 RI.1.1.11, CC#3       The system MAY provide the ability to conduct key wo
IN.2.4.1     C                                           2 RI.1.1.11, CC#3       The system MAY retrieve and display information base
IN.2.4.1     C                                           3 RI.1.1.11, CC#3-4     The system MAY allow full text and metadata selection
IN.2.4.1     C                                           4 RI.1.2.2, CC#6        The system MAY provide the ability to search and retri
IN.2.5                                                0
                               Statement: Store and manage
             H Store and Manage Health Record Information health record information as structured and unstructured dataDescription: U
IN.2.5.1                       Statement: Record Information
                                               DC.1.1 0
             F Manage Unstructured HealthCreate, capture, and maintain unstructured health record information.Description: Unstructured
IN.2.5.1     C                                           1 RI.1.1.1, CC#6        1. The system SHALL provide the ability to capture un
                                                           RI.1.2.1, CC#6
IN.2.5.1     C                                           2 RI.1.1.11             2. The system SHALL provide the ability to extract uns
IN.2.5.1     C                                           3 RI.1.1.2              3. The system SHALL provide the ability to update uns
IN.2.5.1     C                                           4                       4. The system SHALL conform to function IN.2.1 (Data
                                                           RI.1.1.13
                                                           RI.1.2.1, CC#11-14

IN.2.5.1     C                                             5 RI.1.1.5              5. The system SHOULD provide the ability to present a
                                                             RI.1.1.6
IN.2.5.1     C                                             6 RI.1.1.1, CC#11       6. The system MAY provide the ability to tag unstructu
IN.2.5.1     C                                             7 RI.1.1.2, CC#1-7      7. The system SHALL provide the ability to append co
IN.2.5.1     C                                             8 RI.1.1.2, CC#1-7      8. The system SHALL provide the ability to append un
IN.2.5.1     C                                             9 RI.1.1.2, CC#1-7      9. The system SHALL provide the ability to append au
IN.2.5.1     C                                            10 RI.1.1.11, CC#11      The system MAY provide the ability to convert non-stru
IN.2.5.2     F                  Statement: Create, capture, and maintain structured health record information.Description: Structured hea
                                                        0
                 Manage Structured Health Record Information
IN.2.5.2     C                                             1 RI.1.1.1, CC#6        1. The system SHALL capture structured health record
                                                             RI.1.2.1, CC#6
IN.2.5.2     C                                             2 RI.1.1.5              2. The system SHALL retrieve structured health record
                                                             RI.1.1.11
IN.2.5.2     C                                             3 RI.1.1.2              3. The system SHALL provide the ability to update stru
IN.2.5.2     C                                             4                       4. The system SHALL conform to function IN.2.1 (Data
                                                             RI.1.1.13
                                                             RI.1.2.1, CC#11-14

IN.2.5.2     C                                             5 RI.1.1.11              5. The system SHALL provide the ability to report struc
IN.2.5.2     C                                             6 RI.1.1                 6. The system SHALL provide the ability to track struct
                                                             RI.1.2.1
IN.2.5.2     C                                             7 RI.1.1.11, CC#3-5      7. The system SHOULD provide the ability to retrieve e
IN.2.5.2     C                                             8 RI.1.1.2, CC#1-7       8. The system SHALL provide the ability to append co
IN.2.5.2     C                                             9 RI.1.1.2, CC#1-7       9. The system SHALL provide the ability to append str
IN.2.5.2     C                                            10 RI.1.1.2, CC#1-7       10. The system SHALL provide the ability to append a
IN.2.5.3     F                  Statement: Support grammatical and lexical integrity of the health record and provide ready user assistanc
                 Manage Health Information Record Quality0
IN.2.5.3     C                                             1                        The system SHOULD support an integrated realm-bas
                                                             CP, CPS
IN.2.5.3     C                                             2                        The system SHOULD support an integrated realm-bas
                                                             [added 25 August]
IN.2.5.3     C                                             3                        The system SHOULD support an integrated realm-bas

IN.2.5.4                     Statement: Manage health record information during the various states of completion.Description: Health r
             H Manage Record States                 0 Move to RI.1.3
IN.2.5.4.1                                          0
             F Pending State Statement: Manage health record information that may be initiated or pended but is not yet completed.Des
IN.2.5.4.1   C                                         1                       The system SHOULD provide the ability to define the l
IN.2.5.4.1   C                                         2                       The system MAY provide a notification to the author or
IN.2.5.4.1   C                                         3                       The system MAY display pending documents or notes
                                                         Move to RI.1.3.1
IN.2.5.4.1   C                                         4                       IF the system displays pending notes, THEN it SHALL
IN.2.5.4.1   C                                         5                       The system SHOULD allow the author to update a doc
                                                                 Move to RI.1.3.1


IN.2.5.4.1   C                                                6                         The system SHOULD administratively close a docume
IN.2.5.4.1   C                                                7                         The system SHALL apply a date/time stamp and ident
IN.2.5.4.2   F                   Statement: Manage health
                 Amended, Corrected or Augmented State 0 record information that may be amended, corrected or augmented after finaliza
IN.2.5.4.2   C                                                1                         The system SHALL provide the ability for the author of
IN.2.5.4.2   C                                                2                         The system SHALL allow the author of a document or
                                                                Move to RI.1.3.2
IN.2.5.4.2   C                                                3                         The system SHALL record and display with the amend
IN.2.5.4.2   C                                                4                         The system SHALL provide the ability to notate that an
IN.2.5.4.2   C                                                5                         The system SHALL identify the current version and pro
IN.2.5.4.3   F                   Statement: Retain previous versions of a
                 Document Succession Management and Version Control document or note and manage succession. 

                                                           0                                                              Description: The sys
IN.2.5.4.3   C                                                1                         The system MAY provide the ability to specify docume
IN.2.5.4.3   C                                                2 Move to RI.1.3.3        The system SHALL provide the author or a designee t
IN.2.5.4.3   C                                                3                         The system SHALL record and display the date, time a
IN.2.5.4.3   C                                                4                         The system SHALL manage the succession of docume
IN.2.5.4.4   F   Retraction      Statement: Remove a document from view if it is deemed erroneous and cite the reason. 

                                                           0                                                                   Description: Re
IN.2.5.4.4   C                                                1                         The system SHALL provide the ability to retract a docu
                                                                Move to RI.1.3.4
IN.2.5.4.4   C                                                2                         The system SHOULD provide the ability to identify the
IN.2.5.4.4   C                                                3                         The system SHOULD provide the ability to capture and
IN.2.5.5     F                    Templates Allow users to0 create
                 Manage Macros, Statement: and Pre-Defined Text macros, templates and pre-defined text.Description: This function improve
IN.2.5.5     C                                                1                         The system SHALL provide the ability for an authorize
IN.2.5.5     C                                                2                         The system SHALL provide the ability for an authorize
IN.2.5.5     C                                                3                         The system SHALL provide the ability for an authorize
                                                                CP, CPS
IN.2.5.5     C                                                4                         The system SHALL provide the ability for an authorize
                                                                [added 25 August]
IN.2.5.5     C                                                5                         The system SHALL provide the ability for an authorize
IN.2.5.5     C                                                6                         The system SHALL provide the ability for an authorize
IN.2.5.5     C                                                7                         The system SHALL provide the ability for an authorize
IN.2.5.5     C                                                8                         The system SHALL provide the ability for an authorize
IN.2.5.6     F                   Statement: Import or link 0
                 Locate External Health Record Informationexternal patient health record informationDescription: Prior to actually accessing
                                                                Combine with
IN.2.5.6     C                                                1                         The system MAY provide the ability to store a link to pa
                                                                RI.1.5?
IN.2.5.6     C                                                2                         The system MAY provide the ability to import linked pa
IN.2.5.7     F                   Statement: Support the ability to identify a report or record as complete and identify the status as defined b
                 Health Record Completeness                0
IN.2.5.7     C                                                1                         The system SHALL provide the ability to define timefra
IN.2.5.7     C                                                2                         The system SHOULD provide the ability to flag by pati
IN.2.5.7     C                                                3                         The system SHOULD provide the ability to create a rep
                                                                Move to RI.1.4
IN.2.5.7     C                                                4                         The system SHOULD provide users a visual indicator
IN.2.5.7     C                                                5                         The system SHOULD provide the ability to trigger a re
IN.2.5.7     C                                                6                         The system MAY flag patient information that has been
IN.2.5.7     C                                                7                         IF the system flags patient information from internal or
IN.2.x       F   Enable User Help                          0
IN.2.x       C                                                1 CP, CPS                 The system SHOULD receive queries and render resp
IN.2.x       C                                                2 [added 25 August]       The system MAY send and receive User Help queries
IN.2.x       C                                                3                         The system SHALL provide context-sensitive invokable
.2 Functions/Criteria from 1st Pass Review (R1.1 + Functional Profile recommendations)


The system SHALL provide the ability to store and retrieve health record data and clinical documents for the legally prescribed time or the time specified b
The system SHALL provide the ability to retain inbound data or documents (related to health records) as originally received (unaltered, inclusive of the me

The system SHALL retain the content of inbound data (related to health records) as originally received for the time period designated by users’ scope of pr

The system SHOULD provide the ability to retrieve both the information and business context data within which that information was obtained.

e system SHOULD provide the ability to restore both the information and business context data within which that information was obtained.

The system SHOULD provide the ability to retrieve all available elements included in the definition of a legal medical record (including the audit trail and th
The system MAY (automatically or manually) provide the ability to tag specific EHR data/records for deletion according to the user's scope of practice, orga
the system provides the ability to tag specific EHR data/records for deletion, THEN it SHALL provide the ability to review and confirm the set of tagged dat
the system provides the ability to tag specific EHR data/records for deletion, THEN it SHALL provide the ability to delete the data/records according to the
the system provides the ability to tag specific EHR data/records for deletion, THEN it SHALL provide the ability to confirm that the destruction occured acc
e system MAY provide the ability to undelete EHR data/records according to the user's scope of practice, organizational policy, or jurisdictional law.
The system MAY provide the ability to purge EHR data/records according to policy and legal retentions periods.

The system MAY transmit record destruction date information (if any) along with existing data when transmitting records to another entity.
e system SHALL provide the ability to capture information that was created during system downtime.
e system SHOULD provide the ability to integrate information that was created during system downtime.
e system SHOULD manage health care information for organizations that have multiple facilities according to scope of practice.
the PHR-S provides the ability to identify specific PHR data/records for access removal, THEN the PHR-S SHALL allow PHR Account Holder confirmation

he EHR-S receives information from a PHR-S that the PHR-S Account Holder has marked as "private", the EHR-S SHOULD maintain the notation of "priva
e PHR-S MAY permit the PHR Account Holder to define and apply a classification scheme to structured and unstructured data.

e system SHOULD provide the ability to re-activate system audit trail associated with an archived patient record that has been re-activated.
e system SHALL provide the ability to tag any type of health record as inactivated (logical delete) or deprecated (historical record).
e system SHALL provide the ability to capture the reason for deactivation or deprecation of an entry in the health record.
e system SHALL provide the ability to tag any inactivated or deprecated health record entry as active or un-deprecated.



e system SHOULD provide the ability to secure data/records from un-auditable alteration or unauthorized use for preservation purposes such as a legal ho
e system SHALL provide the ability to preserve records beyond normal retention period according to organizational policy or jurisdictional law.
e system SHOULD provide the ability to identify the reason for preserving records beyond the normal retention period.
e system MAY map medical record elements to the metadata to provide the business context.

e system SHOULD provide the ability to generate a legal hold notice identifying who to contact for questions when a user attempts to alter a record on lega

The system SHALL provide audit capabilities for recording access and usage of systems, data, and organizational resources.
The system SHALL conform to function TI.1.1 (Entity Authentication).

The system SHALL provide audit capabilities indicating the time stamp for an object or data creation.
The system SHALL provide audit capabilities indicating the time stamp for an object or data modification.
The system SHALL provide audit capabilities indicating the time stamp for an object or data extraction.

The system SHALL provide audit capabilities indicating the time stamp for an object or data exchange.
The system SHALL provide audit capabilities indicating the time stamp for an object or data view.
The system SHALL provide audit capabilities indicating the time stamp for an object or data deletion in accordance with users’ scope of practice, organiza
The system SHALL provide audit capabilities indicating original author and author of a change to health record content in accordance with users’ scope of
. The system SHALL provide audit capabilities indicating the viewer of a data set.

. The system SHALL provide audit capabilities indicating the data value before a change or deletion.

. The system SHALL provide audit capabilities to capture system events at the hardware and software architecture level.
. The system SHALL conform to function TI.1.3 (Entity Access Control) to limit access to audit record information to appropriate entities in accordance with
e system SHALL conform to function TI.1.3 (Entity Access Control) to limit access to audit record information for purposes of modification in accordance w
e system SHALL conform to function TI.1.3 (Entity Access Control) to limit access to audit record information for purposes of deletion in accordance with u
. The system SHALL provide the ability to generate an audit report.
. The system SHALL provide the ability to view change history for a particular record or data set in accordance with users’ scope of practice, organizationa
e system SHOULD provide the ability to view change history for a particular data point/field/element in accordance with users’ scope of practice, organizat
. The system SHOULD provide the ability to record system maintenance events for loading new versions of, or changes to, the clinical system.
. The system SHOULD provide the ability to record system maintenance events for loading new versions of codes and knowledge bases.
. The system SHALL provide the ability to record changing user-entered date and time where the clinical system allows this to be done.
e system SHALL provide the ability to record date and time an observation was made or data collected if different than the date and time the data was ent
. The system SHOULD provide the ability to record system maintenance events for creating and restoring of backup.

. The system SHOULD provide the ability to record system maintenance events for archiving any data.

. The system SHALL provide the ability to record system maintenance events for re-activating of an archived patient record.

. The system SHALL provide the ability to record system maintenance events for entry to and exit from the EHR system.
. The system SHALL provide the ability to record system maintenance events for remote access connections including those for system support and maint
. The system SHALL utilize standardized time keeping (for example using the IHE consistent time profile).
. The system SHALL provide the ability to record and report upon audit information using a standards-based audit record format (for example RFC 3881).

. audit event in the case of detection of corrupt or dirty data.
e system SHALL provide the capability to track all clinical alerts.



e system SHALL provide the capability to track all acknowledgements of clinically significant report changes.



e system MAY provide the ability to maintain the configuration information necessary to render prior versions of documents that have been amended.
e system MAY provide the ability to maintain the configuration information necessary to render prior versions of documents that have been appended.
e system MAY provide the ability to maintain the configuration information necessary to render prior versions of documents that have been reviewed.
stem functionality SHOULD track when decision support alerts have been disabled.



e system SHALL prevent edits to and removal of a previously recorded time stamp in an audit trail entry.



e system SHALL prevent edits to and removal of previously recorded audit trail entries.



e system SHOULD provide the ability to annotate or tag previously recorded audit trail entries.

e system SHALL provide the ability to enter the reason that access control functions are being overridden.
the system imports or transmits data sets, THEN the system SHALL include related context information including: source/target system name, system uniq
e system SHOULD provide the ability to securely store audit records and/or metadata.

e system SHALL provide the ability to log access to audit records and/or metadata.

e system SHALL provide the ability to enable or disable logging of auditable events based on organizational policy and jurisdictional law.
e system MAY support logging to a common audit engine using schema and transports such as specified in the Audit Log specification of IHE Audit Trails
e system MAY be able to detect security-relevant events that it mediates and generate audit records for them.
e system SHALL record within each audit record the following information: (1) date and time of the event; (2) the component of the system (e.g. software c
e system SHALL provide the capability to generate reports based on ranges of system date and time that audit records were captured.



e system SHOULD export audit record time stamps using UTC (based on ISO 8601).



e system SHALL ensure audit date/time stamps are consistent with the master system clock.
e system SHALL provide audit capabilities indicating the reason for data creation, change, or deletion.




e system SHOULD capture metadata that identifies the source of non-originated content/data (e.g., templated, copied, duplicated, or boilerplate informatio
e system SHALL retain a minimum metadata set corresponding to health record content in accordance with the legally prescribed timeframe or organizatio
e system SHOULD include the minimum metadata set when health record content is exchanged or disclosed.



The system SHALL conform to function IN.5.1 (Interchange Standards).
The system SHOULD conform to function IN.3 (Registry and Directory Services) to enable the use of registries and directories.
The system SHOULD provide the ability to link entities to external information.
The system SHOULD store the location of each known health record component in order to enable authorized access to a complete logical health record i
e system SHALL provide the ability to manage and coordinate date and time -related information between applications, components, services, systems, an

The system SHALL provide the ability to extract health record information.
IF the extracted data is to be electronically exchanged, THEN the system SHALL conform to function TI.1.6 (Secure Data Exchange) to provide secure dat
The system SHALL provide the ability to de-identify extracted information.



The system SHALL conform to function IN.5.1 (Interchange Standards) to enable data extraction.

The system SHOULD provide the ability to perform paramaterized extraction operations across the complete data set that constitutes the health record of
The system SHOULD provide the ability to perform extraction operations whose output fully chronicles the healthcare process.
e system SHOULD provide the ability to perform extraction operations whose output chronicles the healthcare delivered to a patient.
The system SHALL provide the ability to extract data for administrative purposes.
The system SHOULD provide the ability to extract data for financial purposes.
The system SHOULD provide the ability to extract data for research purposes.
. The system SHALL provide the ability to extract data for quality analysis purposes.
. The system SHOULD provide the ability to extract data for public health purposes.
e system SHOULD provide the ability to extract health records for system migration.
e system SHOULD provide the ability to specify parameters to exclude sensitive or privileged health record content from extraction.
the system exports health record content to multiple recipients, THEN the system SHALL provide the ability to re-transmit the information extracted.



e system MAY provide the ability to conduct key word searches for extraction of health record information.
e system MAY retrieve and display information based on the search parameters (for example: key words).
e system MAY allow full text and metadata selection parameters as a means of filtering data.
e system MAY provide the ability to search and retrieve health record content preserved for a legal hold by type, class or encounter (for example: medical



The system SHALL provide the ability to capture unstructured health record information as part of the patient's EHR.

The system SHALL provide the ability to extract unstructured health record information as part of the patient's EHR.
The system SHALL provide the ability to update unstructured health record information.
The system SHALL conform to function IN.2.1 (Data Retention, Availability and Destruction) to provide the ability to tag as inactive, tag as obsolete, or des



The system SHOULD provide the ability to present and/or transmit unstructured health record information.

The system MAY provide the ability to tag unstructured health record information to organize it according to need (e.g., in a time-related fashion, by applica
The system SHALL provide the ability to append corrected unstructured health record information to the original unstructured health record information.
The system SHALL provide the ability to append unstructured health record information to the original unstructured health record information.
The system SHALL provide the ability to append augmented unstructured health record information to the original unstructured health record information.
e system MAY provide the ability to convert non-structured captured data into structured data.

The system SHALL capture structured health record information as part of the patient EHR.

The system SHALL retrieve structured health record information as part of the patient EHR.

The system SHALL provide the ability to update structured health record information.
The system SHALL conform to function IN.2.1 (Data Retention, Availability and Destruction) to provide the ability to inactivate, obsolete, or destroy structu



The system SHALL provide the ability to report structured health record information.
The system SHALL provide the ability to track structured health record information over time.

The system SHOULD provide the ability to retrieve each item of structured health record information discretely in accordance with the provider's scope of p
The system SHALL provide the ability to append corrected structured health record information to the original structured health record information.
The system SHALL provide the ability to append structured health record information to the original structured health record information.
. The system SHALL provide the ability to append augmented structured health record information to the original structured health record information.

e system SHOULD support an integrated realm-based medical spelling function.
e system SHOULD support an integrated realm-based medical thesaurus function.
e system SHOULD support an integrated realm-based grammar function.




e system SHOULD provide the ability to define the length of time a document or note can be in a pending or inactive state before being administratively clo
e system MAY provide a notification to the author or designate that a pending document or note will be administratively closed after a designated period of
e system MAY display pending documents or notes in accordance with the organization’s business rules.
the system displays pending notes, THEN it SHALL clearly identify that a document or note is pending (incomplete).
e system SHOULD allow the author to update a document or note status to one of:- complete, - complete while retaining incomplete version of the entry if
e system SHOULD administratively close a document or note after a period of inactivity in accordance with its business rules and clearly identify that the n
e system SHALL apply a date/time stamp and identify the author each time a document or note is updated including when opened, when updated, with the

e system SHALL provide the ability for the author of a document or note or a designee to enter an amendment, correction or augmentation.
e system SHALL allow the author of a document or note to indicate whether the change was an amendment (additional information), a correction of errone
e system SHALL record and display with the amendment, correction or augmentation to a document or note, the corresponding date, time and user when
e system SHALL provide the ability to notate that an amendment, correction or augmentation has been made to a document or note each time it is rendere
e system SHALL identify the current version and provide a link or clear direction for accessing previous version(s) of the document or note.

e system MAY provide the ability to specify documents and notes that will be handled as a version when their state changes (e.g. augmented, amended, c
e system SHALL provide the author or a designee the ability to create or revise a document or note and save it as a version.
e system SHALL record and display the date, time and user for the original and updated version(s).
e system SHALL manage the succession of documents in chronological version order.

e system SHALL provide the ability to retract a document from view and retain it such that it is only visible upon specific request and with appropriate auth
e system SHOULD provide the ability to identify the users who viewed the record prior to its retraction and notify them of the retraction.
e system SHOULD provide the ability to capture and retain the reason why the record was retracted.

e system SHALL provide the ability for an authorized user to create personally pre-defined text.
e system SHALL provide the ability for an authorized user to create personal templates.
e system SHALL provide the ability for an authorized user to create personal macros for the insertion of pre-defined text.
e system SHALL provide the ability for an authorized user to create personal macros for the insertion of templates.
e system SHALL provide the ability for an authorized user to create enterprise pre-defined text.
e system SHALL provide the ability for an authorized user to create enterprise templates.
e system SHALL provide the ability for an authorized user to create enterprise macros for the insertion of pre-defined text.
e system SHALL provide the ability for an authorized user to create enterprise macros for the insertion of templates.

e system MAY provide the ability to store a link to patient health records in external systems.
e system MAY provide the ability to import linked patient records or portions thereof from external systems.

e system SHALL provide the ability to define timeframes for completion of specified health record content according to organizational business rules.
e system SHOULD provide the ability to flag by patient/health record number the completeness status of specified health record content noting identified d
e system SHOULD provide the ability to create a report by patient/health record number indicating the completeness status of specified health record cont
e system SHOULD provide users a visual indicator denoting that the content of a specified health record is incomplete according to organizational busines
e system SHOULD provide the ability to trigger a reminder to clinicians for the completion of specified health record content (at the data or report level) ac
e system MAY flag patient information that has been not been previously presented to the clinician.
the system flags patient information from internal or external systems that has not been previously presented to the clinician, then it MAY present a notifica

e system SHOULD receive queries and render responses for data entry and system navigation assistance (User Help).
e system MAY send and receive User Help queries and responses via live online chat.
e system SHALL provide context-sensitive invokable help to guide users through charting steps.
 time or the time specified by organizational policy.
naltered, inclusive of the method in which they were received) for the legally or organizationally prescribed time in accordance with users’ scope of practice

 gnated by users’ scope of practice, organizational policy, or jurisdictional law and automatically tag the data as originating from an outside source.

 n was obtained.




 cluding the audit trail and the decoded translation of anything stored only in code form) in accordance with the users' scope of practice, organizational poli
  ser's scope of practice, organizational policy, or jurisdictional law.
 onfirm the set of tagged data/records before the deletion occurs according to the user's scope of practice, organizational policy, or jurisdictional law.
ata/records according to the user's scope of practice, organizational policy, or jurisdictional law.
 the destruction occured according to the user's scope of practice, organizational policy, or jurisdictional law.
 , or jurisdictional law.




Account Holder confirmation before it occurs, and implement function IN.4 (Auditable Records).

maintain the notation of "private".




 purposes such as a legal hold.
 risdictional law.




mpts to alter a record on legal hold.
 scope of practice, organizational policy, or jurisdictional law.
 rdance with users’ scope of practice, organizational policy, or jurisdictional law.




e entities in accordance with users’ scope of practice, organizational policy, or jurisdictional law.
modification in accordance with users’ scope of practice, organizational policy, or jurisdictional law.
 eletion in accordance with users’ scope of practice, organizational policy, or jurisdictional law.

pe of practice, organizational policy, or jurisdictional law.
scope of practice, organizational policy, or jurisdictional law.
 clinical system.



e and time the data was entered into the system.




or system support and maintenance activities for security and access purposes.

at (for example RFC 3881).




 t have been amended.
 t have been appended.
 t have been reviewed.
et system name, system unique identifier (OID), time, electronic address where applicable.




cification of IHE Audit Trails and Node Authentication (ATNA) Profile.

  the system (e.g. software component, hardware component) where the event occurred; (3) type of event (including: data description and patient identifier




ated, or boilerplate information).
bed timeframe or organizational policy.




mplete logical health record if the EHR is distributed among several applications, services, or devices within the EHR-S.
 nents, services, systems, and devices.



 ange) to provide secure data exchange capabilities.




stitutes the health record of an patient within the system.
 nformation extracted.




unter (for example: medical record entry or report, e-mail, metadata, etc.).




 tive, tag as obsolete, or destroy unstructured health record information.




 e-related fashion, by application-specific groups (such as photographs, handwritten notes, or auditory sounds), or by order of relative importance).
health record information.
 rd information.
d health record information.




 obsolete, or destroy structured health record information.




with the provider's scope of practice, organizational policies, and jurisdictional law.
 record information.

 alth record information.




ore being administratively closed.
 after a designated period of time.



mplete version of the entry if viewed for patient care or used by the system, - mark as erroneous and retain if used for patient care or by the system, or - dis
nd clearly identify that the note was administratively closed.
ned, when updated, with the signature event and when officially closed.



ation), a correction of erroneous information and the reason, or an augmentation to supplement content.
g date, time and user when such action was taken.
r note each time it is rendered or viewed.



.g. augmented, amended, corrected, etc.).




st and with appropriate authorization.




ational business rules.
 d content noting identified deficiencies.
specified health record content noting identified deficiencies.
ng to organizational business rules.
t the data or report level) according to organizational business rules (e.g., complete attestation, complete a section).

hen it MAY present a notification to that clinician, according to user role, scope of practice and/or jurisdictional law.
with users’ scope of practice, organizational policy, or jurisdictional law.

 an outside source.




practice, organizational policy, or jurisdictional law.

y, or jurisdictional law.
ription and patient identifier when relevant); (4) user identity.
 elative importance).




are or by the system, or - discard if never viewed for patient care purposes.

				
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