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 Address
Representing Patient Contact Information for Telecommunications
Representing Patient Date of Birth
Representing Patient Name

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