Section I: Vocabulary/Code Set/Terminology Standards and Implementation Specifications

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Allergies and Intolerances

Representing Patient Allergic Reactions

Representing Patient Allergies and Intolerances; Environmental Substances

Representing Patient Allergies and Intolerances; Food Substances

Representing Patient Allergies and Intolerances; Medications

Clinical Notes

Representing Clinical Notes

Cognitive Status

Representing Patient Cognitive Status

Demographics

Representing Patient Contact Information for Telecommunications

Dietary and Nutritional Needs

Representing Nutrition Assessment, Diagnosis, Interventions and Monitoring/Evaluation

Emergency Medical Services

Representing Health Care Data for Emergency Medical Services

Encounter Diagnosis, Assessment and Plan

Representing Assessment and Plan of Treatment

Representing Patient Dental Encounter Diagnosis

Representing Patient Medical Encounter Diagnosis

Family Health History

Representing Patient Family Health History

Functional Status/Disability

Representing Patient Functional Status and/or Disability

Goals

Representing Patient Goals

Health Care Providers, Family Members, and Other Caregivers

Representing Health Care Providers

Representing Provider Role in Team Care Settings

Representing Relationship Between Patient and Another Person

Imaging (Diagnostics, Interventions and Procedures)

Representing Imaging Diagnostics, Interventions and Procedures

Immunizations

Representing Immunizations – Administered

Representing Immunizations – Historical

Industry and Occupation

Representing Patient Industry and Occupation

Laboratory

Representing Laboratory Tests

Representing Laboratory Values/Results

Medications

Representing Patient Medications

Nursing

Representing Clinical/Nursing Assessments

Representing Nursing Interventions

Representing Outcomes for Nursing

Representing Patient Problems for Nursing

Patient Clinical “Problems” (i.e., conditions)

Representing Patient Clinical “Problems” (i.e., Conditions)

Preferred Language

Representing Patient Preferred Language (Presently)

Pregnancy Status

Representing Patient Pregnancy Status

Procedures

Representing Dental Procedures Performed

Representing Medical Procedures Performed

Provenance

Representing Data Provenance

Race and Ethnicity

Representing Patient Race and Ethnicity

Research

Representing Data for Biomedical and Health Services Research Purposes

Sex at Birth, Sexual Orientation and Gender Identity

Representing Patient Gender Identity

Representing Patient Sex (At Birth)

Representing Patient-Identified Sexual Orientation

Social, Psychological, and Behavioral Data

Representing Alcohol Use

Representing Depression

Representing Drug Use

Representing Exposure to Violence (Intimate Partner Violence)

Representing Financial Resource Strain

Representing Food Insecurity

Representing Housing Insecurity

Representing Level of Education

Representing Physical Activity

Representing Social Connection and Isolation

Representing Stress

Representing Transportation Insecurity

Tobacco Use

Representing Patient Electronic Cigarette Use (Vaping)

Representing Patient Second Hand Tobacco Smoke Exposure

Representing Patient Tobacco Use (Smoking Status)

Units of Measure

Representing Units of Measure (For Use with Numerical References and Values)

Vital Signs

Representing Patient Vital Signs