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 | Social Determinants of Health | Congregate Living | Shared housing includes a broad range of settings, such as apartments, condominiums, student or faculty housing, national and state park staff housing, transitional housing, and domestic violence and abuse shelters | HL7 CDA: C-CDA Characteristics of Home Environment template HL7 FHIR: US Public Health Characteristics of Home Environment LOINC: 75274-1 "Characteristics of residence" Value set: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.11.20.9.49/expansion (Residence and Accommodation Type) |
Nedra Garrett | CDC | ||
| Level 0 | Patient Summary and Plan | Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment. |
Clinical Decision Support Data | Data and reporting used for risk stratification, optimization of patient outcomes, detection of decompensation, clinical and patient education. |
SNOMED CT |
Grace Cordovano | Enlightening Results | |
| 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 | Oncology Adverse events | complications (serious- hospitalization, death) |
Laura Esserman | University of California - San Francisco | |||
| 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 | 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 | Pregnancy Information | Multiple Gestation | Multiple gestation is pregnancy with more than one baby at a time. Examples include pregnancy with twins, triplets, and quadruplets. Multiple gestation is a type of high-risk pregnancy that occurs in approximately three percent of pregnancies. |
SNOMED CT 16356006 Multiple pregnancy (disorder) LOINC 45371-2 Multiple pregnancy |
Andrea Fourquet | IHE USA | ||
| 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 | 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 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Collection Method | This is the collection method of the specimen sent for laboratory testing. |
SNOMED CT® |
Sanjeev Tandon on behalf of CDC | CDC | |
| Level 0 | Pregnancy Information | Corrected Estimated Due Date | The Estimated Due Date that has been corrected during the period before birth. |
LOINC 57060-6 Estimated date of delivery Narrative 11778-8 Delivery date Estimated 53692-0 Delivery date Estimated from conception date 11780-4 Delivery date Estimated from ovulation date 57063-0 Delivery date Estimated from quickening date 90368-2 Delivery date Estimated from physical exam 57064-8 Delivery date Estimated from date fundal height reaches umb 11779-6 Delivery date Estimated from last menstrual period 53694-6 Delivery date Estimated from prior gestational age assessment SNOMED CT 161714006 | Estimated date of delivery (observable entity) 289206005 | Estimated date of delivery from last period (observable entity) 33714007 | Corrected (qualifier value) |
Andrea Fourquet | IHE USA | ||
| Level 0 | Pregnancy Information | Planned Pregnancy | Assessing patients for planned pregnancy information reduces the risk of adverse health effects for the woman, fetus, and neonate by working with the woman to optimize health, address modifiable risk factors, provide education and interventions. |
SNOMED CT |
Andrea Fourquet | IHE USA | ||
| Level 0 | Pregnancy Information | Last Menstrual Period (LMP) | Date of the first day of the last menstrual period. |
LOINC : 8665-2 Last menstrual period start date IHE 1.3.6.1.4.1.19376.1.5.3.1.3.18 HL7 FHIR observation - https://www.hl7.org/fhir/observation-example-date-lastmp.html CMS - https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/dwnlds/R81CPpdf.pdf (Pg. 4, ) |
Andrea Fourquet | IHE USA | ||
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Antepartum Summary Note | The Antepartum Summary Note defines the aggregation of significant events, diagnoses, and plans of care derived from the visits over the course of an antepartum episode. It is a summary of the most critical information antepartum care providers capture and share regarding the status of a patient’s pregnancy. It is represented in part by Estimated Due Dates and summaries of the various antepartum visits. The information is aggregated data from which the patient’s interactions with care providers are captured. It includes data such as the patient’s allergies, advance directives, care planning, and selected histories. The antepartum summary note includes information such as structured evaluation of risk (e.g., PRAPARE, homelessness, AHC-HRSN screening tool, etc.) for any maternal health SDOH data related to conditions in which people live, learn, work, and play and their effects on health risks and outcomes; plan of care including social support interventions including but not limited to access to care; education; income; food stability; housing; neighborhood characteristics; safety; transportation security; violence/abuse preventions, ETOH, Smoking, Substance use disorder assessment and treatment drug abuse prevention and treatment; living arrangement; Social support involvement baby father involvement; etc. | SNOMED CT 276986009 Antepartum LOINC: 57061-4 Antepartum flowsheet panel Narrative https://loinc.org/57061-4/ 57055-6 Antepartum summary note https://loinc.org/57055-6/ ICD9 CM Complications of Pregnancy, Childbirth and the Puerperium http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.111.11.1021 ICD10CM, SNOMEDCT Complications of Pregnancy, Childbirth and the Puerperium http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.111.12.1012 Pregnancy https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.378/expansion |
Andrea Fourquet | IHE USA | |
| Level 0 | Special Alerts for Care Handoffs | Internal devices LOINC | Stents |
ICD 10, SNOMED, LOINC, RxNorm |
Holly Miller, MD | MedAllies | ||
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Ventilator set tidal volume | The tidal volume set on the ventilator if the patient is receiving mechanical ventilation. |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication experience | FHIR Resource: HL7 FHIR R4 MedicationStatement, aka R5 MedicationUsage Data element: MedicationStatement.status; MedicationUsage.takenAsOrdered Values in http://hl7.org/fhir/CodeSystem/medication-statement-status: {active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken} These are defined in terms of taking; i.e., “active” in MedicationRequest means that the prescription can be filled, but in MedicationStatement, means that the patient is taking it. FHIR R5 target is to remove “status” and create “use,” with values { Taking | Taking as directed | Taking not as directed | Not Taking | Unknown (unable to obtain)} AVS/PVS system uses “I am taking this med {As written | Differently | Not taking | Unsure}” |
Maureen Layden, MD, MPH | United States Department of Veterans Affairs | ||
| Level 0 | Special Alerts for Care Handoffs | Special equipment needed LOINC | Oxygen |
ICD 10, SNOMED, LOINC, RxNorm |
Holly Miller, MD | MedAllies | ||
| Level 0 | Special Alerts for Care Handoffs | External devices LOINC | Lines Tubes Drains Catheters Date/time prior urinary catheter removed |
ICD 10, SNOMED, LOINC, RxNorm |
Holly Miller, MD | MedAllies |