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 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Trauma Activation or Trauma Alert Type with Activation Date and Activation Time | To be used with trauma patients to have activation type (full, partial or activation/alert, etc.) and date/time of trauma activation type. |
Valerie Brockman | UCHealth | ||
| Level 0 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Individual Administering Vital Signs | Identify the role of the individual taking the vital signs, differentiating between inputs that are from a care team member, patient or family/caregiver, as separate from an automated device or home monitoring system. |
For care team members: Examples include but are not limited to National Provider Identifier (NPI) and National Council of State Boards of Nursing Identifier (NCSBN ID). For FDA approved devices: FDA Unique Device Identification (UDI) System |
Tayler Williams | American Medical Informatics Association (AMIA) | |
| Level 0 | Cancer Care | Staging System | A cancer staging system is used to describe the extent of cancer in the body. There are many staging systems. Some, such as the TNM staging system, are used for many types of somatic cancer. Others are specific to a particular type of cancer (Source: NCI). Examples of non-TNM staging systems include the Cotswolds Modifications of the Ann Arbor Staging Classification, Revised International Staging System (R-ISS), and Rai and Binet staging systems for chronic lymphocytic leukemia. |
SNOMED CT specifies codes for describing different cancer staging systems. |
May Terry | MITRE Corporation | ||
| Level 0 | Cancer Care | Secondary Cancer Condition | Also known as secondary malignant neoplasm, secondary cancer condition is used to describe either a new primary cancer or cancer that has spread from the place in which it started to other parts of the body (Source: NCI). |
Three terminologies are commonly referenced for the exchange of secondary/metastatic cancer conditions: |
May Terry | MITRE Corporation | ||
| Level 0 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Total Intake | The total volume that the patient received during a calendar day, through all sources of access (e.g. intravenous, enteral, oral, peritoneal, pleural, intrathecal, intravesicular, rectal) | LOINC 9097-7 Fluid balance 24hrs SNOMED CT 251856003 Fluid balance |
Ali Abbas MD | UCSF | |
| Level 0 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Urine Output | The total urine output during a calendar day, from all sources including voids, bladder catherization, urostomy, nephrostomy tubes. | LOINC 9097-7 Fluid balance 24hrs SNOMED CT 251856003 Fluid balance |
Ali Abbas MD | UCSF | |
| Level 0 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Total Output | The total volume that the patient put out during a calendar day, from all sources, including urine, stool, and drains like chest tubes, surgical drains, intrathecal catheters, external ventricular drains, peritoneal catheters. | LOINC 9097-7 Fluid balance 24hrs SNOMED CT 251856003 Fluid balance |
Ali Abbas MD | UCSF | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Start/End Date | The start and end date of a medication order. |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Recorded Date | When the event was recorded |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Identifier | Business identifier for the event – important as multiple adverse events may affect a patient within the same visit or location. |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Outcome Status | Adverse Event Status – i.e. in-progress, completed, entered-in-error, unknown | HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Actuality | Did the event (harm) occur or is there potential for harm – ie. Actual, potential |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Category | Type of harm – wrong patient, medication mishap, wrong body site, etc. |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Adverse Event Type | Event or incident that occurred or was averted |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Subject | Subject impacted by event - reference to Patient, Practitioner, Related Person, etc. |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Occurrence | Time period of event – date/time, period, timing when the event occurred |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Detected | Date/Time the event was detected |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Contributing Factor | Contributing factors suspected to have increased the probability or severity of the adverse event |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Participant(s) | Who was involved in the adverse event or the potential adverse event and what they did | HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Study | Research study that the subject is enrolled in |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. |