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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 2.72

Documented findings of a tested specimen including structured and unstructured components.

Both standards are required:

• SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release
• The Unified Code of Units for Measure, Revision 2.1

Pharmacologic agent used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

• RxNorm® Full Monthly Release, July 5, 2022

Optional:

• National Drug Code (NDC), July 19, 2022

Name component following family name that may be used to describe a person's position in a family.

Documentation of a specific instance of sex.

Both values must be supported:

• SNOMED CT U.S. Edition: 248152002 (Female)
• SNOMED CT U.S. Edition: 248153007 (Male)

Known or estimated year, month, and day of the patient's birth.

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 1.2 (July 2021)

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 1.2 (July 2021)

• IETF (Internet Engineering Task Force) Request for Comment (RFC) 5646, “Tags for
  Identifying Languages”, September 2009

Adopted at 45 CFR 170.207(g)(2)

Place where a person is located or may be contacted

• Project US@ Technical Specification for Patient Addresses, Final Version 1.0

Numbers and symbols to contact an individual when using a phone.

Both standards are required

• ITU-T E.123, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - General provisions concerning users: Notation for national and international telephone numbers, email addresses and web addresses, February 2001
• ITU-T E.164, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - Numbering plan of the international telephone service, The international public telecommunication numbering plan, November 2010

Adopted at 45 CFR 170.207(q)(1)

Condition, diagnosis, or reason for seeking medical attention.  

• Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release
• International Classification of Diseases ICD-10-CM 2022

Activity performed for or on a patient as part of the provision of care.

• SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release
• Current Procedural Terminology (CPT®) 2022, as maintained and distributed by the American Medical Association, for physician services and other health care services, and Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by HHS.
• For technology primarily developed to record dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services.

Optional:

• International Classification of Diseases ICD-10-PCS 2022

Date and time of author action.

Organization associated with author.

Assessment of a patient's smoking behaviors.

• SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release