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 | Patient Demographics/Information | 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 | Patient Demographics/Information | 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 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Member Identifier | Identifies an individual covered by the benefits offered by an employer or healthcare insurer. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| 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 Result/Report | Interpreted results of clinical tests that may include study performed, reason performed, findings, and impressions. Includes both structured and unstructured (narrative) components. |
Melissa Ayres | SSA | ||
| 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. |
Functional Status | Represents assessments of a patient’s capabilities, or their risks of development or worsening of a condition or problem (e.g., Morse Scale - falls, Bradon Scale - pressure ulcer, VR-12 Health Survey, CAGE – alcohol use disorder) |
|
Holly Miller, MD | MedAllies | |
| 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. |
Disability Status | Represents assessments of an individual's physical, cognitive, intellectual, or psychiatric disabilities (e.g., vision, hearing, memory, activities of daily living) |
|
Grace Cordovano | Enlightening Results | |
| Draft USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Occupation Industry | A self-reported term for the primary business activity of an entity for which a person works, including volunteer work. For a military position, this is the self-reported branch of service. |
|
Nedra Garrett | CDC | |
| Draft USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Job Occupation |
A self-reported term for the type of work done by a person. For a military position, this is the primary occupational specialty |
Occupational Data for Health |
Nedra Garrett | CDC | |
| Draft USCDI V3 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Relationship to Subscriber | Relationship of a person to the primary insured person in an insurance plan. |
Mark Roberts | Leavitt Partners | ||
| Draft USCDI V3 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Coverage Status | The presence or absence of coverage for a particular encounter or claim. |
Mark Roberts | Leavitt Partners | ||
| Draft USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Tribal Affiliation |
|
Laura Conn | |||
| USCDI V3 | Assessment and Plan of Treatment | Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
Assessment and Plan of Treatment |
Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
||||
| USCDI V3 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Consultation Note |
Response to request from a clinician for an opinion, advice, or service from another clinician. |
|
|||
| USCDI V3 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Discharge Summary Note |
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. |
|
|||
| USCDI V3 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
History & Physical |
Summary of current and past conditions and observations used to inform an episode of care. (e.g. admission, surgery, or other procedure) |
|
|||
| USCDI V3 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Procedure Note |
Synopsis of non-operative procedures. (e.g., interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation) |
|
|||
| USCDI V3 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Progress Note |
Summary of a patient’s interval status during an encounter (e.g., hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter) |
|
|||
| USCDI V3 | Goals | Desired state to be achieved by a patient. |
Patient Goals | Desired outcomes of patient's care. |
||||
| 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. |
Health Concerns |
Health-related issue or worry. (e.g., weight gain, cancer risk) |
||||
| USCDI V3 | Immunizations | Record of vaccine administration. |
Immunizations |
Vaccine product administered, planned, or reported. |
Both standards are required
|