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 |
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| USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Occupation Industry |
Type of business that compensates for work or assigns work to an unpaid worker or volunteer. (e.g., U.S. Army, cement manufacturing, children and youth services) |
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Nedra Garrett | CDC | |
| USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Occupation |
Type of work of a person. (e.g., infantry, business analyst, social worker) |
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Nedra Garrett | CDC | |
| USCDI V3 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Relationship to Subscriber |
Relationship of a patient to the primary insured person. |
Mark Roberts | Leavitt Partners | ||
| USCDI V3 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Coverage Status |
Presence or absence of health care insurance. |
Mark Roberts | Leavitt Partners | ||
| USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Tribal Affiliation |
Tribe or band with which an individual associates. |
Laura Conn | |||
| Draft USCDI V4 | Patient Summary and Plan | Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment. |
Assessment and Plan of Treatment |
Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
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| Draft USCDI V4 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Consultation Note |
Response to request from a clinician for an opinion, advice, or service from another clinician. Examples include but are not limited to dermatology, dentistry, and acupuncture. |
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| Draft USCDI V4 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Discharge Summary Note |
Synopsis of a patient’s admission and course in a hospital or post-acute care setting. Usage note: Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization. Examples include but are not limited to dermatology discharge summary, hematology discharge summary, and neurology discharge summary. |
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| Draft USCDI V4 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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History & Physical |
Summary of current and past conditions and observations used to inform an episode of care. Examples include but are not limited to admission, surgery, and other procedure. |
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| Draft USCDI V4 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Procedure Note |
Synopsis of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation. |
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| Draft USCDI V4 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Progress Note |
Summary of a patient’s interval status during an encounter. Examples include but are not limited to hospitalization, outpatient visit, and treatment with a post-acute care provider, or other healthcare encounter. |
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| Draft USCDI V4 | Goals | Desired state to be achieved by a patient. |
Patient Goals | Desired outcomes of patient's care. |
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| Draft USCDI V4 | 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. Examples include but are not limited to weight gain and cancer risk. |
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| Draft USCDI V4 | Immunizations | Record of vaccine administration. |
Immunizations |
Vaccine product administered, planned, or reported. |
Both standards are required:
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| Draft USCDI V4 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Tests |
Analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health. |
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| Draft USCDI V4 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Values/Results |
Documented findings of a tested specimen including structured and unstructured components. |
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| Draft USCDI V4 | 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. |
Optional:
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| Draft USCDI V4 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
First Name | |||||
| Draft USCDI V4 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Last Name | |||||
| Draft USCDI V4 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Previous Name |