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 V2 Patient Demographics/Information

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

Gender Identity

A person’s internal sense of being a man, woman, both, or neither.

Gender Identify must be coded in accordance with SNOMED CT® and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor, attributed as follows:

  • Male. 446151000124109
  • Female. 446141000124107
  • Female-to-Male (FTM)/Transgender Male/Trans Man. 407377005
  • Male-to-Female (MTF)/Transgender Female/Trans Woman. 407376001
  • Genderqueer, neither exclusively male nor female. 446131000124102
  • Additional gender category or other, please specify. nullFlavor OTH
  • Choose not to disclose. nullFlavor ASKU

Adopted at 45 CFR 170.207(o)(2)

A. Taylor ONC
USCDI V2 Patient Demographics/Information

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

Sexual Orientation

A person’s identification of their emotional, romantic, sexual, or affectional attraction to another person

Sexual orientation must be coded in accordance with SNOMED CT® and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor, attributed as follows:

  • Lesbian, gay or homosexual. 38628009
  • Straight or heterosexual. 20430005
  • Bisexual. 42035005
  • Something else, please describe. nullFlavor OTH
  • Don't know. nullFlavor UNK
  • Choose not to disclose. nullFlavor ASKU

Adopted at 45 CFR 170.207(o)(1)

A. Taylor ONC
USCDI V2 Immunizations

Record of vaccine administration.

Immunizations
  • IIS: Current HL7 Standard Code Set, CVX -- Vaccines Administered, updates through April 6, 2021
  • Vaccine National Drug Code (NDC) Directory – Vaccine NDC Linker Table, updates through May 18, 2021
USCDI V2 Patient Demographics/Information

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

Suffix
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 Vital Signs

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

BMI Percentile (2 - 20 years)
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
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 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:

  • Female. F
  • Male. M
  • Unknown. nullFlavor UNK

Adopted at 45 CFR 170.207(n) 

USCDI V2 Encounter Information

Information related to interactions between healthcare providers and a patient.

Encounter Diagnosis
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • International Classification of Diseases ICD-10-CM 2021
Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
USCDI V2 Clinical Notes

Narrative patient data relevant to the context identified by note types.

  •  
  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 
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 2.70

  • Progress Note (LOINC® code 11506-3)
USCDI V2 Allergies and Intolerances

Harmful or undesired physiological responses associated with exposure to a substance.

Substance (Medication)
  • RxNorm® Full Monthly Release, June 7, 2021
USCDI V2 Patient Demographics/Information

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

Preferred Language

Request for Comment (RFC) 5646, “Tags for Identifying Languages”, September 2009

Adopted at 45 CFR 170.207(g)

USCDI V2 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 1.0 (March 2000)

Adopted at 45 CFR 170.207(f)

USCDI V2 Goals

Desired state to be achieved by a patient.

Patient Goals

Desired outcomes of patient's care.

USCDI V2 Patient Demographics/Information

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

Phone Number Type
USCDI V2 Allergies and Intolerances

Harmful or undesired physiological responses associated with exposure to a substance.

Substance (Drug Class)
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
USCDI V2 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 1.0 (March 2000)

Adopted at 45 CFR 170.207(f)

USCDI V2 Allergies and Intolerances

Harmful or undesired physiological responses associated with exposure to a substance.

Reaction
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
USCDI V2 Patient Demographics/Information

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

Email Address
USCDI V2 Patient Demographics/Information

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

Previous Address

Includes street name, number, city/town, state, and zip code.