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 |
|---|---|---|---|---|---|---|---|---|
| USCDI V3 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Time |
Date/times related to an encounter. (e.g., scheduled appointment time, check in time, start and stop times) |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V3 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Disposition |
Place or setting to which the patient left a hospital or encounter. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V3 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Diagnosis |
Coded diagnoses associated with an episode of care. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| USCDI V3 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Dose |
Amount of a medication for each administration. |
Joel Andress | CMS | ||
| USCDI V3 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Date of Diagnosis | Date of first determination by a qualified professional of the presence of a problem or condition affecting a patient. |
Steven Lane | Sutter Health | ||
| USCDI V3 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Date of Resolution |
Date of subsiding or termination of a symptom, problem, or condition. |
Steven Lane | Sutter Health | ||
| USCDI V3 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Name | Al Taylor | ONC | |||
| USCDI V3 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Identifier |
Sequence of characters used to uniquely refer to a member of the care team. (e.g., National Provider Identifier (NPI), National Council of State Boards of Nursing Identifier (NCSBN ID)) |
Al Taylor | ONC | ||
| USCDI V3 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Location |
Place where care is delivered by a care team member. (e.g., clinic address, location description) |
Al Taylor | ONC | ||
| USCDI V3 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Role |
Responsibility of an individual within the care team. (e.g., primary care physician, caregiver) |
Al Taylor | ONC | ||
| USCDI V3 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Telecom |
Phone or email contact information for a care team member |
|
Keith W. Boone | Audacious Inquiry | |
| USCDI V3 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Location |
Place where a patient’s care is delivered. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V3 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Dose Units of Measure |
Units of measure of a medication. (e.g., milligrams, milliliters) |
|
Maria Michaels | CDC | |
| USCDI V3 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Indication |
Sign, symptom, or medical condition that leads to the recommendation of a treatment, test, or procedure. |
Maria Michaels | CDC | ||
| USCDI V3 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Fill Status |
State of a medication with regards to dispensing or other activity. (e.g., dispensed, partially dispensed, not dispensed) |
Robert C Dieterle | Submitted on behalf of the Da Vinci Project | ||
| 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/Cognitive Status |
Assessment of a patient's level of cognitive functioning. (e.g., 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 | |
| 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 |
State or condition of being pregnant or intent to become pregnant. (e.g., pregnant, not pregnant, intent to become pregnant, unknown) |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| USCDI V3 | Assessment and Plan of Treatment | Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
SDOH Assessment |
Screening questionnaire-based, structured evaluation (e.g., PRAPARE, Hunger Vital Sign®, AHC-HRSN screening tool) for a Social Determinants of Health-related risk. (e.g., food insecurity, housing instability, or transportation insecurity) |
Optional:
|
Mark Savage for Gravity Project | Gravity Project | |
| 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 | |
| USCDI V3 | Goals | Desired state to be achieved by a patient. |
SDOH Goals |
Desired future states (e.g., food security) for an identified Social Determinants of Health-related health concern, condition, or diagnosis. (e.g., food insecurity) |
|
Mark Savage for Gravity Project | Gravity Project |