Information about the provenance of all information recorded and any changes to an information record for audit purposes:
All information records in an Adult Social Care Record (MODS) must be Versioned Records.
All Versioned Records must include a Change Log that captures information about when a record was created, modified, completed and attested (authorised) and by whom. If a Versioned Record has been attested a Document can be associated with the Change Log that proves the attestation e.g. a signature. In addition the change log should capture a system identifier for the System where the change was recorded in.
If the Versioned Record is immutable, then the specific information about the Change (in the Change Log) could be inferred by examining each version of the record, otherwise the information about the specific Change (in the Change Log) must be detailed enough to recreate the record at a specific point in time.