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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| Draft USCDI V2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Discharge Summary Note | A synopsis of a patient’s admission and course in a hospital or post-acute care setting. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
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| Draft USCDI V2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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History & Physical | Documents the current and past conditions and observations of the patient. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
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| Draft USCDI V2 | Goals | Desired state to be achieved by a patient. |
Patient Goals | Desired outcomes of patient's care. |
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| Draft USCDI V2 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Tests | The name of the 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 V2 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Laboratory Report Narrative |
Contains a consulting specialist’s interpretation of the laboratory report. This data element was reclassified from Clinical Notes to Laboratory. |
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| Draft USCDI V2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Progress Note | Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
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| Draft USCDI V2 | Health Concerns | Health related matter that is of interest, importance, or worry to someone who may be the patient, patient’s family or patient’s health care provider. |
Health Concerns | |||||
| Draft USCDI V2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Diagnostic Imaging Test | The name of the test performed which generates visual images (radiographic, photographic, video, etc.) of anatomic structures; and requires interpretation by qualified professionals. |
• Logical Observation Identifiers Names and Codes (LOINC®) version 2.69 |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| Draft USCDI V2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Imaging Narrative |
Contains a consulting specialist’s interpretation of diagnostic imaging data. This data element was reclassified from Clinical Notes to Diagnostic Imaging. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
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| Draft USCDI V2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Diagnostic Imaging Report | Interpreted results of imaging test that includes the study performed, reason, findings, and impressions. Includes both structured and unstructured (narrative) components. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.69 |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| Draft USCDI V2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Procedure Note | Encompasses non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and other specialty’s procedures. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
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| Draft USCDI V2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Consultation Note |
Contains the response to request from a clinician for an opinion or advice from another clinician. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
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| Draft USCDI V2 | Immunizations | Record of vaccine administration. |
Immunizations |
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| USCDI V2 | 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 V2 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Diagnosis |
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Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Sex (Assigned at Birth) | Birth sex must be coded in accordance with HL7 Version 3 (V3) Standard, Value Sets for AdministrativeGender and NullFlavor attributed as follows:
Adopted at 45 CFR 170.207(n) |
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| USCDI V2 | 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 V2 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Location |
Physical location of provider or other care team member |
Al Taylor | ONC | ||
| USCDI V2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Inhaled Oxygen Concentration |
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| USCDI V2 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Identifier | Al Taylor | ONC |