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 Special Alerts for Care Handoffs Risk Scores LACE - https://www.mdcalc.com/calc/3805/lace-index-readmission

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs Medications RxNorm, SNOMED

Important drug-drug interactions
High risk medications e.g.:
anticoagulants
opiates
sedatives
electrolyte altering
hypoglycemics
antipsychotics
Immunosuppressants
Tricyclic antidepressants
Complicated regimens e.g.:
loading
tapering
sliding scale
precise schedule
Instructions for missed or late medications

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs Special equipment needed LOINC

Oxygen
Hoyer
Special fit wheelchair
Bariatric
Extended length
Wound care
VAC
Prosthetics, orthoses

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs Internal devices LOINC

Stents
Monitors
Pumps
Defibrillators

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs External devices LOINC

Lines Tubes Drains Catheters Date/time prior urinary catheter removed

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs Infections ICD 10, SNOMED

Infection precautions (COVID 19, MPV, C diff, MRSA, MDRO, etc.) Vaccination status especially unvaccinated or contraindicated

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs Conditions with substantial risk of complications ICD 10, SNOMED

Serious chronic mental illness
Transplants
Substance Use Disorder
Incontinence
Healed pressure injury
Active pressure injury

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs Safety risks ICD 10, SNOMED, LOINC

Risks to safety of individual and/or organization/staff
Weight bearing limitations
Victim of abuse with or without restraining order (domestic violence, financial abuse, etc.)

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs Patient behaviors with risk to self or others (reported or observed) ICD 10, SNOMED

Examples Include:
Wandering Z91.83
Falls Z91.81
Confusion F05
Aggressive behavior F02.81
Physical violence R45.6
Suicidal ideation R45.851

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs Scheduling (time specific interventions) LOINC

Indicate timing for scheduling essential testing, treatments, consults, procedures, and follow-up appointments.

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Newborn's Delivery Information Reason CCHD oxygen saturation screening not performed

The reason that CCHD screening for newborns was not performed on this patient.

LOINC 73698-3 - Reason CCHD oxygen saturation screening not performed (including Preferred Answer List LL2458-9)

Craig Newman Altarum
Level 0 Health Status Assessments

Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.

Health Literacy Status Degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

LOINC 95866-0, BRIEF health literacy screening tool [BRIEF]; LOINC LL3268-1 (for answers)

Nedra Y Garrett CDC
Level 0 Newborn's Delivery Information CCHD Newborn Screening Interpretation

The result of the screening of the preductal and postductal oxygen saturation measurements.

LOINC 73700-7 - CCHD newborn screening interpretation
LOINC Preferred Answer List LL2453-0

Craig Newman Altarum
Level 0 Newborn's Delivery Information Hearing loss risk indicators

Documentation of specific hearing loss risk indicators for the newborn.

58232-0 - Hearing loss risk indicators (including Preferred Answer List LL862-4)

Craig Newman Altarum
Level 0 Newborn's Delivery Information Newborn hearing screen reason not performed of ear - left

The reason why the hearing screen was not done in left ear.

73739-5 - Newborn hearing screen reason not performed of Ear - left (including Preferred Answer List LL2769-9)

Craig Newman Altarum
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 Cancer Care Radiation Therapy Structure Name

TG-263 (https://www.aapm.org/pubs/reports/RPT_263.pdf) name of structure, if it exists.

Elizabeth Covington University of Michigan
Level 0 Cancer Care Radiation Therapy Prescription Number of Sessions Per Week

The number of radiation therapy treatment sessions delivered per week. Some radiation therapy protocols do not deliver treatment every day.

Elizabeth Covington University of Michigan
Level 0 Cancer Care Structure Type

Defines if the radiation therapy structure a target structure (e.g. PTV, CTV, GTV) or an organ at risk.

Standard Values (List): Target; Organ at Risk

Elizabeth Covington University of Michigan