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 Medical Devices

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

Medical Device Name

The name of the medical device.

Sandi Mitchell J P Systems, Inc.
Level 0 Medical Devices

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

Measured ventilator peak inspiratory pressure

Measured peak inspiratory pressure if the patient is receiving mechanical ventilation

Airway type LOINC LL5542-7
PEEP LOINC 20077-4
Pressure support LOINC 20079-0
Plateau Pressure LOINC 76259-1
Tidal Volume LOINC 76221-1
Respiratory Rate LOINC 33438-3

Ali Abbasi MD- on behalf of the I-SPY COVID investigators I-SPY COVID Trial Investigators
Level 0 Medical Devices

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

Ventilator measured plateau pressure

The measured plateau pressure on the ventilator if the patient is receiving mechanical ventilation

Airway type LOINC LL5542-7
PEEP LOINC 20077-4
Pressure support LOINC 20079-0
Plateau Pressure LOINC 76259-1
Tidal Volume LOINC 76221-1
Respiratory Rate LOINC 33438-3

Ali Abbasi MD- on behalf of the I-SPY COVID investigators I-SPY COVID Trial Investigators
Level 0 Medical Devices

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

Ventilator Mode

The mode of mechanical ventilation if the patient is receiving mechanical ventilation. Could refer to LOINV 20124-4 for options.

Airway type LOINC LL5542-7
PEEP LOINC 20077-4
Pressure support LOINC 20079-0
Plateau Pressure LOINC 76259-1
Tidal Volume LOINC 76221-1
Respiratory Rate LOINC 33438-3

Ali Abbasi MD- on behalf of the I-SPY COVID investigators I-SPY COVID Trial Investigators
Level 0 Special Alerts for Care Handoffs Conditions with substantial risk of complications ICD 10, SNOMED

Serious chronic mental illness
Transplants
Substance Use Disorder
Incontinence
Healed pressure injury
Active pressure injury

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs Infections ICD 10, SNOMED

Infection precautions (COVID 19, MPV, C diff, MRSA, MDRO, etc.) Vaccination status especially unvaccinated or contraindicated

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
Level 0 Special Alerts for Care Handoffs Internal devices LOINC

Stents
Monitors
Pumps
Defibrillators

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
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 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
PEEP LOINC 20077-4
Pressure support LOINC 20079-0
Plateau Pressure LOINC 76259-1
Tidal Volume LOINC 76221-1
Respiratory Rate LOINC 33438-3

Ali Abbasi MD- on behalf of the I-SPY COVID investigators I-SPY COVID Trial Investigators
Level 0 Special Alerts for Care Handoffs Special equipment needed LOINC

Oxygen
Hoyer
Special fit wheelchair
Bariatric
Extended length
Wound care
VAC
Prosthetics, orthoses

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs Medications RxNorm, SNOMED

Important drug-drug interactions
High risk medications e.g.:
anticoagulants
opiates
sedatives
electrolyte altering
hypoglycemics
antipsychotics
Immunosuppressants
Tricyclic antidepressants
Complicated regimens e.g.:
loading
tapering
sliding scale
precise schedule
Instructions for missed or late medications

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs Risk Scores LACE - https://www.mdcalc.com/calc/3805/lace-index-readmission

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Care Team Members

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

Caregiver of disabled person

Person serving as a primary caregiver for a disabled person.

American Community Survey disability value set

Charles Mayo University of Michigan, American Association of Physicists in Medicine
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. 
Tumor Board Notes

This may be a interdisciplinary note or a specific note for tumor boards.

https://loinc.org/85231-9/

Leslie Kelly Hall Engaging Patient Strategy
Level 0 Medical Devices

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

Ventilator set positive end expiratory pressure

The set positive end expiratory pressure (PEEP) if the patient is receiving mechanical ventilation or a biphasic positive airway pressure.

Airway type LOINC LL5542-7
PEEP LOINC 20077-4
Pressure support LOINC 20079-0
Plateau Pressure LOINC 76259-1
Tidal Volume LOINC 76221-1
Respiratory Rate LOINC 33438-3

Ali Abbasi MD- on behalf of the I-SPY COVID investigators I-SPY COVID Trial Investigators
Level 0 Medical Devices

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

Ventilator set respiratory rate

The set respiratory rate if the patient is receiving mechanical ventilation

Airway type LOINC LL5542-7
PEEP LOINC 20077-4
Pressure support LOINC 20079-0
Plateau Pressure LOINC 76259-1
Tidal Volume LOINC 76221-1
Respiratory Rate LOINC 33438-3

Ali Abbasi MD- on behalf of the I-SPY COVID investigators I-SPY COVID Trial Investigators
Level 0 Medical Devices

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

Ventilator pressure support

The pressure support above PEEP if the patient is receiving mechanical ventilation

Airway type LOINC LL5542-7
PEEP LOINC 20077-4
Pressure support LOINC 20079-0
Plateau Pressure LOINC 76259-1
Tidal Volume LOINC 76221-1
Respiratory Rate LOINC 33438-3

Ali Abbasi MD- on behalf of the I-SPY COVID investigators I-SPY COVID Trial Investigators
Level 0 Medical Devices

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

Medical Device Category

AMIA recommends a more thorough breakdown of the Medical Devices Data Class. For medical devices, there should be a distinguishment between permanent versus temporary data classes. Temporary devices for example PICC line, indwelling foley and suprapubic catheters, and wound vacs. Medical applications should also be included as they are considered medical digital devices, such as digital therapeutics, standard languages, payor exchanges, what is included and excluded in this category.

FDA Unique Device Identification (UDI) System

Tayler Williams American Medical Informatics Association (AMIA)
Level 0 Clinical Notes

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

  •  
  • 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. 
Postpartum Summary Note The postpartum summary note supports the inclusion of any interval medical history since delivery, physical and pelvic examination information, review of newborn status, discussion of birth control options, depression and intimate partner violence screenings, immunization review, counseling regarding any future pregnancies, and any interventional education, screenings, tests and results including laboratory. The postpartum 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 55410009 Maternal postpartum 86569001 Postpartum state LOINC: 57076-2 Postpartum hospitalization treatment Narrative https://loinc.org/57076-2/ 57083-8 Labor and Delivery record panel https://loinc.org/57083-8/ 92576-8 Maternal discharge summary - recommended IHE set https://loinc.org/92576-8/ 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, SNOMED CT 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