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 |
|---|---|---|---|---|---|---|---|---|
| Draft USCDI V3 | Narrative patient data relevant to the context identified by note types.
|
Progress Note | Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.71
|
||||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Gender Identity | A person’s internal sense of being a man, woman, both, or neither. |
Gender Identify must be coded in accordance with SNOMED CT® and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor, attributed as follows:
Adopted at 45 CFR 170.207(o)(2) |
A. Taylor | ONC | ||
| Draft USCDI V3 | 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. |
Pregnancy Status | Indicator that a patient is currently pregnant, not pregnant, or that their pregnancy status is unknown currently, as it relates to potential risks and exposures. |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | |||
| Draft USCDI V3 | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Telecom | Electronic contact information of a provider or other care team member |
|
Keith W. Boone | Audacious Inquiry | ||
| Draft USCDI V3 | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
BMI Percentile (2 - 20 years) |
|
|||||
| Draft USCDI V3 | Information related to interactions between healthcare providers and a patient. |
Encounter Type | Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Sex (Assigned at Birth) | Birth sex must be coded in accordance with HL7 Version 3 (V3) Standard, Value Sets for AdministrativeGender and NullFlavor attributed as follows:
Adopted at 45 CFR 170.207(n) |
|||||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Last Name | ||||||
| Draft USCDI V3 | Narrative patient data relevant to the context identified by note types.
|
History & Physical | Documents the current and past conditions and observations of the patient. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.71
|
||||
| Draft USCDI V3 | 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. |
Mental Function | Represents observations related to a patient's current level of cognitive functioning, including alertness, orientation, comprehension, concentration, and immediate memory for simple commands. |
|
Michelle Dougherty | Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup | ||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Previous Address | Includes street name, number, city/town, state, and zip code. |
|||||
| Draft USCDI V3 | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Heart Rate |
|
|||||
| Draft USCDI V3 | Activity performed for or on a patient as part of the provision of care. |
Procedures |
Optional:
|
|||||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Sexual Orientation | A person’s identification of their emotional, romantic, sexual, or affectional attraction to another person |
Sexual orientation must be coded in accordance with SNOMED CT® and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor, attributed as follows:
Adopted at 45 CFR 170.207(o)(1) |
A. Taylor | ONC | ||
| Draft USCDI V3 | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Type | Type of specimen (e.g., nasopharyngeal swab, whole blood, serum, urine, wound swab) on which a lab test is performed. |
Nedra Garrett | Centers for Disease Control and Prevention | |||
| Draft USCDI V3 | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Body Temperature |
|
|||||
| Draft USCDI V3 | The metadata, or extra information about data, regarding who created the data and when it was created. |
Author Organization | Organization associated with author. |
|||||
| Draft USCDI V3 | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Head Occipital-frontal Circumference Percentile (Birth - 36 Months) |
|
|||||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Tribal Affiliation |
|
Laura Conn | ||||
| Draft USCDI V3 | Information related to interactions between healthcare providers and a patient. |
Encounter Time | Represents a date/time related to an encounter (e.g., scheduled appointment time, check in time, start and stop times). |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) |