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 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.

Nutrition Status

A systematic nutrition assessment of an individual's nutrition intake, physical exam, anthropometric measurements, biochemical, and health condition data compared to accepted standards, recommendations, and/or goals to arrive at a determination of the client’s nutrition well-being or malnutrition.

LOINC 75304-6 Nutrition status observation panel

Michelle Ashafa Academy of Nutrition and Dietetics
Level 0 Work Information Job End Date The last day a person worked in a Job. Nedra Garrett CDC
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.

Benefit Payment Status

Indicates the in network or out of network payment status of the claim.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Level 0 Medical Devices

An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose.

Status Date The date associated with the corresponding implantable device status.

standard date formats

TICIA Louise GERBER Health Level Seven International
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.

Procedure Date

Principal medical procedure a patient received during inpatient stay. Current coding methods include: International Classification of Diseases Surgical Procedures (ICD-9). Information located on UB04 (Form Locator 74).
Additional surgical procedure surgical (ICD-9) administered during inpatient stay.
Principal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10).
Additional surgical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10).

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
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.

Revenue Center Code

Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Level 0 Medical Devices

An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose.

Medical Device Use

The use of the medical device.

Sandi Mitchell J P Systems, Inc.
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.

Visual Acuity Mike Schmidt HiQ Services, LLC
Level 0 Cancer Care Provider Reported Toxicity Value

For each Cancer Patient - Provider Reported Toxicity record the Toxicity Value corresponding to the Toxicity Measure specified indicates the severity of the toxicity using the standardized table. specifies what value is measured. For example if CTCAE v5.0 (https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…) the values in the standardized set are 0,1,2,3,4,5

The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) identified this as a high priority element supporting patient care, outcomes research and public policy

Common Terminology Criteria for Adverse Events
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…

Charles Mayo University of Michigan
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 Provenance

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

Custodian Organization Id

An identifier of the custodian organization.

Sarah Gaunt The Association of Public Health Laboratories (APHL)
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 Cancer Care Radiation Therapy Outcome/Disease Status

Status of the disease treated with radiation therapy at the time of the record.
This is vital information both for clinical care and for public health policy
The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) noted a Delphi process to identify standard values recommended for classification. These were

Under Treatment

No evidence of disease (NED)

Stable Disease

Partial Response

Progressive Disease

Indeterminate (possible pseudo-progression)

Complete Response

Biochemical Recurrence

Primary Recurrence

Local Recurrence

Nodal Recurrence

Distant Recurrence

In OORO for each instance record of a Cancer Patient Treatment Outcome, multiple values of Disease Status can be selected e.g. Biochemical Recurrence, Nodal Recurrence

Charles Mayo University of Michigan
Level 0 Cancer Care Provider Reported Toxicity Measure

For each Cancer Patient - Provider Reported Toxicity record the Toxicity Measure specifies what value is measured. For example if CTCAE v5.0 (https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…) is used then the Toxicity Measure would correspond to CTCAE Term (e.g. Dry Mouth, or Dry Mouth)

The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) identified this as a high priority element supporting patient care, outcomes research and public policy

Common Terminology Criteria for Adverse Events
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…

Charles Mayo University of Michigan
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 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 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

Payment member explanation

Payment explanation to a member on an EOB

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
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.

Claim Service Start Date

Date on which services began.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Level 0 Provenance

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

Unique Identifier

Numeric or alphanumeric code that uniquely identifies a document.

Sandi Mitchell J P Systems, Inc.
Level 0 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 
Initial evaluation note

Initial evaluation note, LOINC code = 28636-9, and any LOINC LongName Note which has Initial Evaluation Note as a component.

LOINC https://loinc.org/67781-5/ https://loinc.org/28636-9/ https;//loinc.org/34108-1/

Nedra Garrett Centers for Disease Control and Prevention