USCDI Export for the Public

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Classification Level Sort descending	Data Class Description	Data Element	Data Element Description	Applicable Standards
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Ethnicity		Both standards are required The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997 CDC Race and Ethnicity Code Set Version 1.0 (March 2000) Adopted at 45 CFR 170.207(f)
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Race		Both standards are required The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997 CDC Race and Ethnicity Code Set Version 1.0 (March 2000) Adopted at 45 CFR 170.207(f)
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Date of Birth
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: Female. F Male. M Unknown. nullFlavor UNK Adopted at 45 CFR 170.207(n)
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Suffix
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Middle Name (Including middle initial)
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Previous Name
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Last Name
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	First Name
Draft USCDI V3	Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.	Medications		RxNorm® Full Monthly Release, January 3, 2022
Draft USCDI V3	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.	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 Progress Note (LOINC® code 11506-3)
Draft USCDI V3	Health professional’s conclusions and working assumptions that will guide treatment of the patient.	Assessment and Plan of Treatment
Draft USCDI V3	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.	Consultation Note	Response to request from a clinician for an opinion, advice, or service from another clinician.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.71 Consult Note (LOINC® code 11488-4)
Draft USCDI V3	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.	Discharge Summary Note	A synopsis of a patient’s admission and course in a hospital or post-acute care setting. Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.71 Discharge Summary (LOINC® code 18842-5)
Draft USCDI V3	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.	History & Physical	Documents the current and past conditions and observations of the patient.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.71 Discharge Summary (LOINC® code 34117-2)
Draft USCDI V3	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.	Procedure Note	Encompasses non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and other specialty’s procedures.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.71 Procedure Note (LOINC® code 28570-0)
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.	Health Concerns
Draft USCDI V3	Analysis of clinical specimens to obtain information about the health of a patient.	Tests	The name of the analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
Draft USCDI V3	Record of vaccine administration.	Immunizations		Both standards are required IIS: Current HL7 Standard Code Set, CVX – Vaccines Administered, updates through November 9, 2021 Vaccine National Drug Code (NDC) Directory – Vaccine NDC Linker Table, updates through November 18, 2021
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Preferred Language		Request for Comment (RFC) 5646, “Tags for Identifying Languages”, September 2009 Adopted at 45 CFR 170.207(g)