USCDI Export for the Public

Download CSV
Classification Level Data Class Data Class Description Data Element Data Element Description Applicable Standards Submitter Name Submitter Organization Submission Date
Level 0 Pregnancy Information Plurality

The number of fetuses delivered live or dead at any time in the pregnancy regardless of gestational age, or if the fetuses were delivered at different dates in the pregnancy. (“Reabsorbed” fetuses, those which are not “delivered” (expulsed or extracted from the mother) should not be counted.) Include all live births and fetal losses resulting from this pregnancy.

LOINC codes exist for each of the proposed data elements:

68493-6: Prenatal visits for this pregnancy #

69044-6: Date first prenatal visit

69461-2 Mother's body weight --at delivery

73772-6 The number of fetal deaths this delivery

73773-4 - Number of infants in this delivery delivered alive

57722-1 - Birth plurality of Pregnancy

 Adam Bazer, MPD Integrating the Healthcare Enterprise USA (IHE USA)
Level 0 Pregnancy Information Mother’s Prepregnancy Weight

The weight of the mother before becoming pregnant.

LOINC codes exist for each of the proposed data elements: Last menstrual period start date: 8665-2 Delivery date Estimated: 11778-8 Body weight --pre current pregnancy: 56077-1

 Adam Bazer, MPD Integrating the Healthcare Enterprise USA (IHE USA)
Level 0 Pregnancy Information Mother’s Delivery Weight

The weight of the mother at the time of birth/delivery.

LOINC codes exist for each of the proposed data elements:

68493-6: Prenatal visits for this pregnancy #

69044-6: Date first prenatal visit

69461-2 Mother's body weight --at delivery

73772-6 The number of fetal deaths this delivery

73773-4 - Number of infants in this delivery delivered alive

57722-1 - Birth plurality of Pregnancy

 Adam Bazer, MPD Integrating the Healthcare Enterprise USA (IHE USA)
Level 0 Pregnancy Information Number of Prenatal Visits

The total number of prenatal visits for the mother.

LOINC codes exist for each of the proposed data elements:

68493-6: Prenatal visits for this pregnancy #

69044-6: Date first prenatal visit

69461-2 Mother's body weight --at delivery

73772-6 The number of fetal deaths this delivery

73773-4 - Number of infants in this delivery delivered alive

57722-1 - Birth plurality of Pregnancy

 Adam Bazer, MPD Integrating the Healthcare Enterprise USA (IHE USA)
Level 0 Medications

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

 Medication Prescription Patient The person who is the intended recipient of the medication. While seemingly self-evident as a part of an prescription record, the requirement of the patient being linked to the drug administered is critical

In FHIR R4, https://www.hl7.org/fhir/medicationrequest-definitions.html#MedicationRequest.subject

 Scott Gordon Food and Drug Administration
Level 0 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. 
 Pregnancy History for Death Certificate

Data elements or description that provide a woman's pregnancy history at the time of death.

"LOINC: Summary of death note: 47046-8 Physician Summary of death note: 83796-3 Nurse Summary of death note: 84273-2 US Standard Certificate of Death Hepatitis C Case Report Form "LOINC Codes for death note summaries: https://loinc.org/47046-8/ https://loinc.org/83796-3/ https://loinc.org/84273-2/ US Standard Certificate of Death: https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-ACC.pdf Pregnancy History - While a one to one relationship may not exist between the information in the EHR and what is needed in a state's electronic death registration system (EDRS), the information in the EHR (even if available in longhand), can help inform filling out the following in the EDRS. IF FEMALE: □ Not pregnant within the past year □ Pregnant at the time of death □ Not pregnant, but pregnant within 42 days of death □ Not pregnant, but pregnant 43 days to 1 year before death □ Unknown if pregnant within the past year Hepatitis C Case Report Form: https://www.cdc.gov/hepatitis/pdfs/HepatitisCaseRprtForm.pdf"

 Nedra Garrett Centers for Disease Control and Prevention
Level 0 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. 
 Clinical Notes for Newborn

"Clinical notes information for a newborn may include the Labor and delivery summary record under–Infant data, and maternal progress note. Example information will include breastfeeding information at time of discharge."

"LOINC codes exist for each of the proposed data elements The clinical notes of an new born should capture information such as: 73756-9 | Infant is being breastfed at discharge"

 Nedra Garrett Centers for Disease Control and Prevention
Level 0 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. 
 Telehealth note

Documentation of a clinical encounter that takes place via telehealth.

LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process.

 Swapna Abhyankar Regenstrief Institute, LOINC Document Ontology Subcommittee
Level 0 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. 
 Outpatient Note

Documentation of a clinical encounter that takes place in an outpatient setting. Reason to consider separately (including this here because the "Reason" field for additional elements is truncating my text): This data element has some overlap with other existing and proposed Clinical Notes data elements Outpatient is a setting versus a type of service (Consultation, History & Physical, Discharge Summary, Transfer Summary, etc.). For example, Outpatient consultation notes span the “Consultation Note” and “Outpatient Note” data elements. However, we feel it is important to specify this particular setting because the vast majority of LOINC terms representing outpatient clinical notes aren’t captured in the data elements that represent particular types of service.

LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process.

 Swapna Abhyankar Regenstrief Institute, LOINC Document Ontology Subcommittee
Level 0 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. 
 Transfer summary note

A synopsis of a patient’s admission and clinical course in one setting when being transferred to another setting.

LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process.

 Swapna Abhyankar Regenstrief Institute, LOINC Document Ontology Subcommittee
Level 0 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. 
 Plan of care note

Documentation about expected but pending or ongoing orders, interventions, encounters, services, and procedures for a patient.

LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process.

 Swapna Abhyankar Regenstrief Institute, LOINC Document Ontology Subcommittee
Level 0 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. 
 Referral note

Documentation sent to a consultant, for example, by a primary care provider, summarizing the patient’s clinical history and reason for consult.

LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process.

 Swapna Abhyankar Regenstrief Institute, LOINC Document Ontology Subcommittee
Level 0 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. 
 Expanded list of clinical notes, detailed in Data Element Description

Audiometry/Audiology Audiograms: (68635-2 Audiology Diagnostic study note) Psychology Reports Mental Status Evaluation: (94798-6 Psychology Diagnostic study note) Neuropsychological Testing: (94798-6 Psychology Diagnostic study note) Psychological Testing: (94798-6 Psychology Diagnostic study note) Cardiac Reports Angiogram: (75425-9 Cardiology Diagnostic study note) Cardiac Catheterization: (75425-9 Cardiology Diagnostic study note) Doppler Test (75425-9 Cardiology Diagnostic study note) Electrocardiograph, electrocardiogram (EKG/ECG) result/interpretation: (75425-9 Cardiology Diagnostic study note) EKG/ECG Tracing Image: (75425-9 Cardiology Diagnostic study note) Echocardiogram result/interpretation: (75425-9 Cardiology Diagnostic study note) Stress Testing (exercise, pharma): (83539-7 Cardiology Risk assessment & screening note) Holter monitor: (83539-7 Cardiology Risk assessment & screening note) Neurology Electroencephalogram (EEG): (68556-0 Neurology Diagnostic study note) Electromyogram/nerve conduction (EMG): (68556-0 Neurology Diagnostic study note) Myelogram: (68556-0 Neurology Diagnostic study note) Ophthalmology/Optometry Visual Acuity: (78573-3 Ophthalmology Diagnostic study note) Visual Fields: (78573-3 Ophthalmology Diagnostic study note) Radiology (Interpretations Only; No Images) CT: (68604-8 Ophthalmology Diagnostic study note) MRI: (68604-8 Ophthalmology Diagnostic study note) PET: (68604-8 Ophthalmology Diagnostic study note) X-Ray: (68604-8 Ophthalmology Diagnostic study note) Respiratory DLCO Study: (80792-5 Pulmonary Diagnostic study note) Pulmonary Function Study: (80792-5 Pulmonary Diagnostic study note) Spirometry Test result/interpretation: (80792-5 Pulmonary Diagnostic study note) Spirometry Tracing Image: (80792-5 Pulmonary Diagnostic study note) Surgical Diagnostics Bone Marrow (Biopsy/Aspiration): (48807-2 Bone marrow aspiration report) Colonoscopy: (18746-8 Colonoscopy study report) Endoscopy: (18751-8 Endoscopy study report) Additional Procedures Ultrasound (exclude Doppler): (59282-4 Stress cardiac echo study report) Genetic Testing: (51969-4 Genetics analysis report) Physical Exam: (29545-1 Physical findings narrative)

LOINC—although we would like to see the set of codes constrained as suggested above. In Data Element Description above, we have the suggested LOINC code (showing also the Long Common Name) for each Note in our list. Such constraints are needed in order to allow for semantic interoperability.

 KarenP-SSA Social Security Administration (SSA)
Level 0 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. 
 Clinical Notes for Newborn

Clinical notes information for a newborn may include the Labor and delivery summary record under–Infant data, and maternal progress note. Example information will include breastfeeding information at time of discharge.

LOINC codes exist for each of the proposed data elements The clinical notes of an new born should capture information such as: 73756-9 | Infant is being breastfed at discharge

 Adam Bazer, MPD Integrating the Healthcare Enterprise USA (IHE USA)
Level 0 Work Information Usual Occupation

A self-reported, coded term for the type of work (paid or unpaid) done by a person for the longest amount of time during his or her life, not including voluntary work (done by choice for the benefit of others without compensation).

Occupational Data for Health (Value Set - Occupation ONETSOC Detail (ODH)) https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7901 Occupation CDC Census 2010 https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7186

 Nedra Garrett CDC
Level 0 Newborn's Delivery Information Pregnancy Outcome

The result of the subject’s delivery, such as live birth or not a live birth.

LOINC codes exist for each of the proposed data elements:
11884-4: Gestational age Estimated
64710-7: Was your pregnancy a live birth, stillbirth, miscarriage, abortion, or ectopic pregnancy [PhenX]
9272-6: 1 minute Apgar Score
9274-2: 5 minute Apgar Score
9271-8: 10 minute Apgar Score

73766-8: Place where birth occurred [US Standard Certificate of Live Birth]
• Freestanding birthing center (Freestanding birthing center is defined as one which has no direct physical connection with an operative delivery center.)
• Home birth
• Planned to deliver at home Yes No
• Clinic/Doctor’s Office
• Other (specify, e.g., taxi cab, train, plane, etc.)

8339-4 - Birth weight Measured

 Adam Bazer, MPD Integrating the Healthcare Enterprise USA (IHE USA)
Level 0 Work Information Job Work Classification

A coded term that characterizes the arrangement between the employer and the person in a job, such as 'paid work, self-employed' or 'voluntary work in disaster/emergency response', as reported by the person.

PHVS_WorkClassification_ODH

 Nedra Garrett CDC
Level 0 Work Information Job Work Schedule

A coded term for the typical arrangement of working hours for a job, as reported by the person.

Value Set - Work Schedule (ODH)

 Nedra Garrett CDC
Level 0 Work Information Usual Industry A self-reported term that identifies the kind of business, i.e., primary business activity, in which a person has worked for the longest time while in their Usual Occupation. For a military position, this is the self-reported branch of service. If an appropriate term is not available (e.g., a new kind of business), then a text entry is used.

Occupational Data for Health (Value Set - Industry NAICS Detail (ODH)) https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7900 Industry CDC Census 2010 http://hl7.org/fhir/us/odh/ValueSet-codesystem-industry-cdc-census-2010.html

 Nedra Garrett CDC
Level 0 Encounter Information

Information related to interactions between healthcare providers and a patient.

 Reason for the Encounter

Reason the encounter takes place, expressed as a code.

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