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 Nutrition and Diet Oral Nutritional Supplement A food item consumed to manage calories, protein or other nutrient(s) to enhance nutritional quality; the supplement could be a meal replacement, a part of a meal or consumed as a snack. Examples: Commercial ready-to-use beverages or powdered products to be reconstituted with milk/milk substitute or water, puddings, soups or bars.

HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC

 Becky Gradl Academy of Nutrition and Dietetics
Level 0 Nutrition and Diet Enteral Nutrition Volume The volume of formula to provide at each feeding. This data element must be provided in conjunction with the Enteral Nutrition Type and other Enteral Nutrition data elements.

HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC

 Becky Gradl Academy of Nutrition and Dietetics
Level 0 Nutrition and Diet Enteral Nutrition Rate Speed with which the enteral formula is provided per period of time. This data element must be provided in conjunction with the Enteral Nutrition Type and other Enteral Nutrition data elements.

HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC

 Becky Gradl Academy of Nutrition and Dietetics
Level 0 Nutrition and Diet Enteral Nutrition Frequency Scheduled frequency of enteral feeding. This data element must be provided in conjunction with the Enteral Nutrition Type and other Enteral Nutrition data elements.

HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC

 Becky Gradl Academy of Nutrition and Dietetics
Level 0 Problems

Condition, diagnosis, or reason for seeking medical attention.

 Date of First Noted/Documented

Date of first noted/documented by a qualified professional of the presence of a problem or condition affecting a patient.

Standard Date/Time formats

 Tayler Williams American Medical Informatics Association (AMIA)
Level 0 Referral Referral Category The classification of the referral, or the service being requested. For example a procedure, an intervention such as counseling or education, or a service.

HL7 FHIR US Core ServiceRequest Category Codes HL7 Service Request Category

 Grace Glennon, on behalf of NCQA NCQA
Level 0 Provenance

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

 Element Level GUID

The Element Level Globally Unique Identifier (GUID) ensures that each data element instance:
1) Has a single non-duplicative identifier;
2) Assigned at the point of origination by the source EHR/PHR/HIT system;
3) Inseparably bound to the data element instance;
4) Maintained in perpetuity during the lifespan of that data element instance;
5) From source to use (point of origination to each ultimate point of use), including all intermediate stages and lifecycle events (retention, update/amendment, verification/attestation, exchange...).
6) Can be bound together within a correlated set - elements of content bound to elements of related context.

 Gary Dickinson EHR Standards Consulting
Level 0 Nutrition and Diet Enteral Nutrition Additive Type of modular component to add to the enteral nutrition feeding. This data element must be provided in conjunction with the Enteral Nutrition Type and other Enteral Nutrition data elements.

HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC

 Becky Gradl Academy of Nutrition and Dietetics
Level 0 Nutrition and Diet Enteral Nutrition Flush The amount and frequency of water to run through the feeding tube to prevent the feeding tube from getting clogged. Also used for providing medication.

HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC

 Becky Gradl Academy of Nutrition and Dietetics
Level 0 Nutrition and Diet Eating/drinking assistive device External devices that are designed, made, or adapted to assist a person with eating and/or drinking

HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC

 Becky Gradl Academy of Nutrition and Dietetics
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
Example answer list:
Yes (qualifier value) LA33-6
No - I do not want to talk about contraception today because I am here for something else; LA32389-1
No - This question does not apply to me/I prefer not to answer; LA32390-9
No - I am already using contraception; LA32393-3
No - I am unsure or don't want to use contraception; LA32391-7
No - I am hoping to become pregnant in the near future; LA32392-5

 Dr. Christine Dehlendorf Person-Centered Reproductive Health Program, Family and Community Medicine, University of California, San Francisco
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 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 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 Patient Demographics/Information

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

 Country of Usual Residence

The patient’s usual country of residence

HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) based on FHIR R4 HL7 CDA® R2 Implementation Guide: Public Health Case Report - the Electronic Initial Case Report (eICR) HL7 FHIR: Country of Residence profile HL7 CDA: Country of Residence template

 Laura Conn
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 Patient Demographics/Information

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

 Organ Donor

Represents the wishes of an individual to donate their organs, tissues, and/or blood as a deceased or living donor.

 Grace Cordovano Enlightening Results
Level 0 Patient Demographics/Information

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

 Tribal Enrollment

A tribe of which the patient is an enrolled member.

HL7 FHIR: US Public Health Tribal Affiliation extension
HL7 CDA: Tribal Affiliation template
HL7 Value Set: TribalEntityUS

 Laura Conn
Level 0 Care Team Members

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

 Proxy Decision Maker

Individual designated by the patient to make healthcare decisions for the patient in the event the patient is unable.

 Holly Miller, MD MedAllies
Level 0 Clinical Tests

Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.

 Audiogram

Standard under development by HL7 in Diagnostic Audiology Reporting HL7 V2 Implementation Guide
https://confluence.hl7.org/display/PHWG/Diagnostic+Audiology+Reporting+…
Subset of this implementation guide that = Audiogram is
•Diagnostic audiology tests performed
•Results of the diagnostic evaluation: left ear, including type, severity, and configuration of hearing loss, if a diagnosis is made.
•Results of the diagnostic evaluation: right ear, including type, severity, and configuration of hearing loss, if a diagnosis is made.
•Results of diagnostic evaluation in the form of audiogram

 Troy Kaji Contra Costa Health Services