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 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Location | Location of facility which delivered a person’s health care or related services |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Draft USCDI V3 | 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. |
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 | 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. |
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 | Assessment and Plan of Treatment | Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
SDOH Assessment | Structured evaluation of risk (e.g., PRAPARE, Hunger Vital Sign, AHC-HRSN screening tool) for any Social Determinants of Health domain such as food, housing, or transportation security. SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. |
|
Mark Savage for Gravity Project | Gravity Project | |
| Draft USCDI V3 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
SDOH Problems/Health Concerns |
Social Determinants of Health-related health concerns, conditions, or diagnoses. (e.g., homelessness, food insecurity) |
|
Mark Savage for Gravity Project | Gravity Project | |
| Draft USCDI V3 | Goals | Desired state to be achieved by a patient. |
SDOH Goals | Identifies a future desired condition or change in condition related to an SDOH risk in any domain and is established by the patient or provider. (e.g., Has adequate quality meals and snacks, Transportation security-able to access health and social needs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. |
|
Mark Savage for Gravity Project | Gravity Project | |
| Draft USCDI V3 | Procedures | Activity performed for or on a patient as part of the provision of care. |
SDOH Interventions |
A service offered to a patient to address identified Social Determinants of Health concerns, problems, or diagnoses (e.g., Education about Meals on Wheels Program, Referral to transportation support programs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. |
|
Mark Savage for Gravity Project | Gravity Project | |
| Draft USCDI V3 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Subscriber Identifier | The identifier assigned to the individual that selects benefits offered by an employer or healthcare insurer. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| Draft USCDI V3 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Payer Identifier | The identifier defining a payer entity. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| Draft USCDI V3 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Coverage Type | Categories of health care payers. (e.g., Medicare, TRICARE, Commercial Managed Care - PPO) |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Draft USCDI V3 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Group Identifier | The identifier associated with a specific health insurance plan typically provided thorough an employer. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| Draft USCDI V3 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Result Status |
Representing the stage of completeness of a result of a laboratory test. |
Maria Michaels | CDC | ||
| Draft USCDI V3 | 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. |
Clinical Test |
Non-imaging or non-laboratory test. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Draft USCDI V3 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Diagnostic Imaging Test | The name of the test performed which generates visual images (radiographic, photographic, video, etc.) of anatomic structures; and requires interpretation by qualified professionals. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.71 |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| Draft USCDI V3 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Diagnostic Imaging Report | Interpreted results of imaging test that includes the study performed, reason, findings, and impressions. Includes both structured and unstructured (narrative) components. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | ||
| Draft USCDI V3 | Laboratory | 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 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Reason for Referral |
An explanation or justification for why this service is being requested or was provided. |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Draft USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Related Person's Relationship | Represents the relationship between a patient and a person involved in the care of a patient (e.g., parent, next-of-kin, guardian, custodian). |
||||
| Draft USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Related Person's Name | The name of a person involved in the care of a patient, but who is not the target of that care. |
CDC-defined HL70063 |
Nedra Garrett | Centers for Disease Control and Prevention | |
| Draft USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Date of Death | Known or estimated year, month, and day of the patient's death. |
Jeff Lyall | Cigna |