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 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Modifier Code -3 | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
<prTag>identifier | Globally unique identifier |
ASTM/ANSI E 1714 Standard Guide for Properties of a Universal Healthcare Identifier (UHID), originally approved in 1995. Most recently approved in 2007. |
Barry R Hieb | Global Patient Identifiers, Inc. (GPII) | |
| Level 0 | Social Determinants of Health | Self-Identified Need for Contraception (SINC) | Self-Identified Need for Contraception screening tool for primary care settings. |
Self-Identified Need for Contraception (SINC) LOINC: 98076-3 |
Dr. Christine Dehlendorf | Person-Centered Reproductive Health Program, Family and Community Medicine, University of California, San Francisco | ||
| 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 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication List Type | Codification of the type of medication list (e.g. Active medication list, Reconciled medication list, Discharged medication list, Discontinued (Inactive) medication list, Patient generated medication list (Different nuance, needs to be reviewed by a clinician before it can be entered as an active medication list), Medications that are private and need patient consent to share, Medication administration list, Medication administration list for public health and CDC reporting (e.g., for COVID, Antibiotics for Antibiotic Stewardship), Discharged medication list (Feeds the discharge summary that contains the Discharged medication list and when transferring within a hospital from one level of care to another (intersystem), a transfer medication list is used for MR). |
LOINC |
Shelly Spiro | Pharmacy HIT Collaborative | |
| 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 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
Religious & Spiritual Preferences | Defines an individual's religious or spiritual preferences which helps to support whole-person care in the in-patient and out-patient settings as well as in the palliative and end-of-life care settings. |
Grace Cordovano | Enlightening Results | ||
| 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 | Work Information | Occupational Exposure/Hazard | A hazard that is specific to a person's work or work environment for a single job and with which the person might come in contact. A hazard is a source of potential harm to an individual's physical or mental health (e.g., biological, chemical, physical, psychological, radiological). |
LOINC History of Occupational hazard | 87729-0 |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| 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 | Travel Information | Transportation Details | Information about transportation details such as the type of transport along with any associated information (e.g., name of cruise ship, flight number, airport, seat number, cabin number). |
HL7 FHIR: US Public Health Transportation Details profile HL7 CDA: Transportation Details Organizer/Transportation Details Observation templates VSAC Value Set: Transport vehicle type |
Nedra Garrett | CDC | ||
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
HL7-Identifier | Globally unique identifier assigned to a patient by an organization asserting compliance with the referenced HL7 FHIR Identify Matching IG |
A system exists for using the identifier within HL7 FHIR transactions, particularly those invoking $match, but the standard also intends for the identifier to be used in other health information exchange transaction types as well as in non-healthcare specific transactions for example in OpenID Connect identity claims. |
Julie Maas | EMR Direct | |
| 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. |
Mental Health Status | Assessment of or screening for the presence of a mental or behavioral health condition. |
Various specific mental health status measures exist in LOINC, including the PHQ-9 for depression, the GAD-7 for anxiety, and the C-SSRS for suicide risk. |
Michael Schoenbaum | National Institute of Mental Health | |
| Level 0 | Travel Information | Purpose of Travel | Purpose of travel (business, tourism, etc.) |
HL7 FHIR: US Public Health Travel History profile (Observation.component) HL7 CDA: Purpose of Travel Observation template SNOMED: 280147009 "Travel Purpose" PHIN VADS Value Set: PHVS_TravelPurpose_CDC |
Nedra Garrett | CDC | ||
| Level 0 | Work Information | Job Employer Phone | Phone number of the individual's employer. | Sarah Gaunt | The Association of Public Health Laboratories (APHL) | |||
| Level 0 | Work Information | Job Title | Name of the job position held by an individual. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | |||
| 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 | Newborn's Delivery Information | Birth Weight | The weight of the infant/fetus at birth/delivery. |
LOINC codes exist for each of the proposed data elements: 11884-4 - Gestational age Estimated 73766-8 - Place where birth occurred [US Standard Certificate of Live Birth] 64710-7 - Was your pregnancy a live birth, stillbirth, miscarriage, abortion, or ectopic pregnancy [PhenX] 8339-4 - Birth weight Measured 8305-5 - Body height --post partum 9272-6 - 1 minute Apgar Score 9274-2 - 5 minute Apgar Score 9271-8 - 10 minute Apgar Score |
TICIA Louise GERBER | Health Level Seven International |