USCDI Export for the Public
| Classification Level Sort descending | Data Class | Data Class Description | Data Element | Data Element Description | Applicable Standards | Submitter Name | Submitter Organization | Submission Date |
|---|---|---|---|---|---|---|---|---|
| Level 0 | Goals | Desired state to be achieved by a patient. |
Outcome Code | Identifies the change (or lack of change) at the point when the status of the goal is assessed |
HL7 FHIR |
Shelly Spiro | Pharmacy HIT Collaborative | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Maternal Social Determinants of Health Note | The Maternal Social Determinants of Health Note supports the aggregation of significant events, social problems and related health concerns, and plans of care derived from the visits over the course of a maternal care episode. It is a summary of the most critical information maternal care providers capture and share regarding the status of a maternal patient's social issues. The information is aggregated data from which the patient’s interactions with healthcare and social services providers are captured. The Maternal Social Determinants of Health Note includes information such as structured evaluation of risk (e.g., PRAPARE, homelessness, AHC-HRSN screening tool, etc.) for any maternal health SDOH data related to conditions in which people live, learn, work, and play and their effects on health risks and outcomes; plan of care including social support interventions including but not limited to access to care; education; income; food stability; housing; neighborhood characteristics; safety; transportation security; violence/abuse preventions, ETOH, Smoking, Substance use disorder assessment and treatment drug abuse prevention and treatment; living arrangement; Social support involvement baby father involvement; etc. | SNOMED CT 183425000 Social care 61072005 Social factor 315042007 Social support 161152002 Social problem 310134006 Social services 406551008 Social assessment 405076007 Social support status 108329005 Social context finding LOINC 52234-2 Medical social services treatment plan, Assessment information Set 52218-5 Medical social services treatment plan, Referral information Set 29762-2 Social history Narrative 91642-9 Medical Outcomes Study Social Support Survey panel 91663-5 Social support index ICD10 Z60.9 Problem related to social environment, unspecified Z60.8 Other problems related to social environment ICD9 CM Complications of Pregnancy, Childbirth and the Puerperium ICD10CM, SNOMEDCT Complications of Pregnancy, Childbirth and the Puerperium Pregnancy SNOMED CT: https://www.snomed.org/ LOINC: https://loinc.org/ ICD10: https://www.icd10data.com/ |
Asha G Immanuelle | Center For Black Women's Wellness | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Autopsy Report | An autopsy is a post-mortem medical examination that a forensic pathologist, coroner, or medical examiner performs on the body of a deceased person. |
Grace Cordovano | Enlightening Results | ||
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Other Payer Paid Amount | The reduction in the payment amount to reflect the current carrier as a secondary, teritary, etc, payer. May be multiple occurrences if the current carrier is a teritary, etc. carrier. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
DME Orders | Medically necessary equipment (and the corresponding order) that a physician prescribes for use in a patient’s home, including wheelchairs, walkers, and hospital beds. |
The Centers for Medicare & Medicaid Services (CMS) annually updates a spreadsheet that contains a list of the HCPCS codes for DME MAC and Part B MAC jurisdictions to reflect codes that are either added or discontinued (deleted) each year. The jurisdiction list is an Excel file and is available at https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center |
Matt Reid | American Medical Association | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administered Reason Reference | Reference to a condition that is the reason for the medication administration. |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Dose Units | The units of measure associated with the amount of medication given at one administration event |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Dose | The amount of the medication given at one administration event. |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administered Code | A code (or set of codes) that specify the medication that was administered. |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Date Medication Administered | A specific date/time or interval of time during which the administration took place (or did not take place, when the 'notGiven' attribute is true). |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Tumor Board Notes | This may be a interdisciplinary note or a specific note for tumor boards. |
https://loinc.org/85231-9/ |
Leslie Kelly Hall | Engaging Patient Strategy | |
| Level 0 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Caregiver of disabled person | Person serving as a primary caregiver for a disabled person. |
American Community Survey disability value set |
Charles Mayo | University of Michigan, American Association of Physicists in Medicine | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Line Copay Amount | Medical: Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Newborn's Delivery Information | Newborn hearing screen of ear - right | The hearing screening result for the right ear provides coded result values for pass, refer and not performed. There should be separate results for both the right Ear and left ear. |
54109-4 - Newborn hearing screen of Ear - right (including Preferred Answer List LL618-0) |
Craig Newman | Altarum | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter status | Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.html |
Maria Michaels | CDC | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Location Associated Time Period | Encounter type/occurrence: SNOMED CT (example, value set OID: 2.16.840.1.113883.3.666.5.307) HCPCS (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1087) CPT (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1001) HL7 value set, encounter type: https://www.hl7.org/fhir/us/core/ValueSet-us-core-encounter-type.html Encounter Diagnosis/ Primary Diagnosis/Discharge Diagnosis: SNOMED CT ICD-10-CM Discharge Disposition: DischargeDisposition Code System http://terminology.hl7.org/CodeSystem/discharge-disposition Encounter Location: SNOMED HSLOC |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Level 0 | Newborn's Delivery Information | Newborn hearing screen reason not performed of ear - right | The reason why the hearing screen was not done in right ear. |
73742-9 - Newborn hearing screen reason not performed of Ear - right (including Example Answer List LL2769-9) |
Craig Newman | Altarum | ||
| Level 0 | Newborn's Delivery Information | Newborn hearing screen of ear - left | The hearing screening result for the leftear provides coded result values for pass, refer and not performed. There should be separate results for both the right Ear and left ear. |
54108-6 - Newborn hearing screen of Ear - left (including Preferred Answer List LL618-0) |
Craig Newman | Altarum | ||
| Level 0 | Newborn's Delivery Information | Gestational Age at Birth | LOINC codes are available for gestational age |
Kensaku Kawamoto, MD, PhD, MHS | University of Utah | |||
| Level 0 | Cancer Care | Systemic Therapy As Part of Treatment | Was a of systemic therapy used as part of treatment for this diagnosis? |
American Joint Committee on Cancer e.g. AJCC8 |
Charles Mayo, PhD | University of Michigan |