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 |
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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). |
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 |
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. 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 |
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.
|
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 |