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Classification Level Data Class Data Class Description Data Element Data Element Description Applicable Standards Submitter Name Submitter Organization Submission Date
USCDI V3.1 Medications

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

 Medications

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
USCDI V3.1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 First Name
USCDI V3.1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Last Name
USCDI V3.1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Previous Name
USCDI V3.1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Middle Name (Including middle initial)
USCDI V3.1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Name Suffix

Name component following family name that may be used to describe a person's position in a family.
USCDI V3.1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Sex

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)
USCDI V3.1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Date of Birth

Known or estimated year, month, and day of the patient's birth.
USCDI V3.1 Patient Demographics/Information

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 1.2 (July 2021)
USCDI V3.1 Patient Demographics/Information

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 1.2 (July 2021)
USCDI V3.1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

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

Adopted at 45 CFR 170.207(g)(2)
USCDI V3.1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Current Address

Place where a person is located or may be contacted
  • Project US@ Technical Specification for Patient Addresses, Final Version 1.0
USCDI V3.1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Phone Number

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)
USCDI V3.1 Problems

Condition, diagnosis, or reason for seeking medical attention.

 Problems

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
USCDI V3.1 Procedures

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

 Procedures
  • 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) 2022, maintained and distributed by the American Dental Association, for dental services.

Optional:

  • 2022 International Classification of Diseases  ICD-10-PCS 
USCDI V3.1 Provenance

The metadata, or extra information about data, regarding who created the data and when it was created.

 Author Time Stamp

Date and time of author action.
USCDI V3.1 Provenance

The metadata, or extra information about data, regarding who created the data and when it was created.

 Author Organization

Organization associated with author.
USCDI V3.1 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.

 Smoking Status

Assessment of a patient's smoking behaviors.
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release
USCDI V3.1 Unique Device Identifier(s) for a Patient's Implantable Device(s)

Unique identifier(s) for a patient's implantable device(s).

 Unique Device Identifier(s) for a patient's implantable device(s)

Unique numeric or alphanumeric codes that consist of a device identifier and a production identifier.
  • FDA Unique Device Identification System (UDI System)
 Marti Velezis FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII)
USCDI V3.1 Vital Signs

Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.

 Diastolic Blood Pressure

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
  • The Unified Code of Units for Measure, Revision 2.1