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 | 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 | 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 | 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 | 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 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 | 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 | Oral Diet Texture Modifiers | Texture modifications to indicate how to alter the texture of foods to improve safety for patients with swallowing difficulties. For example, “pureed” or “soft & bite-sized”. The ISDDI Framework (https://iddsi.org/Framework) for foods is recommended as the terminology for this data element. | 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 | Oral Diet Fluid Consistency | The required consistency of fluids and liquids provided to improve safety for patients with swallowing difficulties. For example, “moderately thick” or “thin”. The ISDDI Framework (https://iddsi.org/Framework) for drinks is recommended as the terminology for this data element. |
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 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Cannabinoids | As the use of medical cannabis, OTC cannabidiol (CBD), and adult use cannabis (medical marijuana), and recreational cannabis is more frequent - there is the potential for drug-drug interactions; and awareness for peri-operative elective or urgent surgical procedures and/or hospitalizations. It is not just the added sedation - and perhaps safer than opioids - but the emphasis here is that cannabinoids have the real potential to affect the metabolism of OTHER medications especially those that have a narrow therapeutic index or other medications that have high-protein binding. A standardized format will provide the foundation for drug-drug interaction screening - vs. a multitude of inconsistent entries. Although medical cannabis is technically DEA class-1; there is high probability that medical cannabis may be transitioned to DEA class-3 in the very near future (see recent CSR memo added to the 'Use Case' tab). Additionally, this idea is also for cannabidiol (CBD) which is over the counter (OTC) - so not just limited to prescription Epidiolex. Additionally, medical cannabis preparations often have unique dosage forms (e.g., badder, butter). |
Paul T. Kocis, PharmD, MPH | Dept of Pharmacology, Penn State College of Medicine | ||
| Level 0 | Genomics | Molecular Consequence | Molecular consequence is a calculation of the effect of the sequence change if the allele is in a gene (source: NCBI, https://www.ncbi.nlm.nih.gov/clinvar/docs/details/). |
The Sequence Ontology is a collaborative ontology project for the definition of sequence features used in biological sequence annotation. |
May Terry | MITRE Corporation | ||
| 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. |
HHS Disability Status - Mobility | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 The prompt for this data element should be consistent with HHS implementation guide: “Do you have serious difficulty walking or climbing stairs?” https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
Nedra Garrett | CDC | |
| Level 0 | Work Information | Job Start Date | The date a person started working in a Job. | Nedra Garrett | CDC | |||
| Level 0 | Cancer Care | Radiation Therapy Dose Objective | TG-263 (https://www.aapm.org/pubs/reports/RPT_263.pdf) name of DVH metric for the objective |
Elizabeth Covington | University of Michigan | |||
| Level 0 | Work Information | Job Employer Name | The company, organization, or individual that provides compensation for a job or that assigns work to a volunteer, as reported by the person. For a military position, this is the self-reported duty station (home base). |
LOINC® 80427-8 Employer name |
Nedra Garrett | CDC | ||
| Level 0 | Work Information | Job Employer Address | The self-reported Employer Address; this is not necessarily the work location. |
LOINC (r) 80429-4 Employer address |
Nedra Garrett | CDC | ||
| 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 | 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. |
HHS Disability Status - Vision | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 The prompt for this data element should be consistent with HHS implementation guide: “Are you blind or do you have serious difficulty seeing, even when wearing glasses?” https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
Nedra Garrett | CDC | |
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Accommodation | Provides information or details regarding modifications, tools, technologies, and/or other supports needed in order to address any barriers to care that an individual living with a disability(ies) may need in order to improve their care and life with a diagnosis. |
Grace Cordovano | Enlightening Results |