USCDI Export for the Public

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Classification Level Sort descending	Data Class	Data Class Description	Data Element	Data Element Description	Applicable Standards
USCDI V1	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Consultation Note	Contains the response to request from a clinician for an opinion or advice from another clinician.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 Consult Note (LOINC® code 11488-4)
USCDI V1	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Discharge Summary Note	A synopsis of a patient’s admission and course in a hospital or post-acute care setting.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 Discharge Summary (LOINC® code 18842-5)
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Last Name
USCDI V1	Laboratory	Analysis of clinical specimens to obtain information about the health of a patient.	Values/Results	Documented findings of the analysis of a tested specimen. Includes both structured and unstructured (narrative) components.
USCDI V1	Immunizations	Record of vaccine administration.	Immunizations		CDC IIS: Current HL7 Standard Code Set, CVX -- Vaccines Administered, updates through January 31, 2020 CDC National Drug Code (NDC) Directory – Vaccine NDC Linker Table, updates through January 31, 2020
USCDI V1	Goals	Desired state to be achieved by a patient.	Patient Goals	Desired outcomes of patient's care.
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Birth Sex		Birth sex must be coded in accordance with HL7 Version 3 (V3) Standard, Value Sets for AdministrativeGender and NullFlavor attributed as follows: Female. F Male. M Unknown. nullFlavor UNK Adopted at 45 CFR 170.207(n)
USCDI V1	Health Concerns	Health related matter that is of interest, importance, or worry to someone who may be the patient, patient’s family or patient’s health care provider.	Health Concerns
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Suffix
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Race		Both standards are required The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997 CDC Race and Ethnicity Code Set Version 1.0 (March 2000) Adopted at 45 CFR 170.207(f)
USCDI V1	Assessment and Plan of Treatment	Health professional’s conclusions and working assumptions that will guide treatment of the patient.	Assessment and Plan of Treatment
USCDI V1	Medications	Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.	Medications		RxNorm®, January 6, 2020 Full Release Update
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Middle Name (including middle initial)
USCDI V1	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	History & Physical	Documents the current and past conditions and observations of the patient.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 Discharge Summary (LOINC® code 34117-2)
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	First Name
USCDI V1	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Procedure Note	Encompasses non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and other specialty’s procedures.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 Procedure Note (LOINC® code 28570-0)
USCDI V1	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Progress Note	Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 Progress Note (LOINC® code 11506-3)
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Previous Name
USCDI V1	Laboratory	Analysis of clinical specimens to obtain information about the health of a patient.	Tests	The name of the analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Date of Birth