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
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

Previous Address

Includes street name, number, city/town, state, and zip code.

USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

Phone Number Type
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

Email Address
USCDI V1 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • 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 Care Team Members

Information about a person who participates or is expected to participate in the care of a patient.

Care Team Member
USCDI V1 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • 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 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • 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. 
Pathology Report Narrative

Contains a consulting specialist’s interpretation of the pathology report.

USCDI V1 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • 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. 
Imaging Narrative

Contains a consulting specialist’s interpretation of diagnostic imaging data.

Logical Observation Identifiers Names and Codes (LOINC®) version 2.67

  • Diagnostic Imaging Study (LOINC® code 18748-4
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 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • 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.

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  • 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 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. 
Laboratory Report Narrative

Contains a consulting specialist’s interpretation of the laboratory report.

Draft USCDI V2

Unique identifier(s) for a patient's implantable device(s).

Marti Velezis FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII)
Draft USCDI V2

Activity performed for or on a patient as part of the provision of care.

Procedures
  • Healthcare Common Procedure Coding System (HCPCS)
  • Current Procedural Terminology (CPT), 2021
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release
  • For technology primarily developed to record dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services.

Optional:

  • International Classification of Diseases ICD-10-PCS 2021
Draft USCDI V2

Representing a patient’s smoking behavior.

Smoking Status

Representing a patient’s smoking behaviors.

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release
Draft USCDI V2

The metadata, or extra information about data, regarding who created the data and when it was created.

Author Time Stamp
Draft USCDI V2

Information about a person who participates or is expected to participate in the care of a patient.

Care Team Member Identifier Al Taylor ONC
Draft USCDI V2

Tests that result in visual images requiring interpretation by a credentialed professional.

Diagnostic Imaging Test

The name of the test performed which generates visual images (radiographic, photographic, video, etc.) of anatomic structures; and requires interpretation by qualified professionals.

• Logical Observation Identifiers Names and Codes (LOINC®) version 2.69

Swapna Abhyankar Regenstrief Institute, LOINC Document Ontology Subcommittee
Draft USCDI V2

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.

Draft USCDI V2

The metadata, or extra information about data, regarding who created the data and when it was created.

Author Organization

Organization associated with author.