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 |
|---|---|---|---|---|---|---|---|---|
| Draft USCDI V5 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Indication |
Sign, symptom, or medical condition that is the reason for giving or taking a medication. |
|
Maria Michaels | CDC | |
| Draft USCDI V5 | 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. Examples include but are not limited to dispensed, partially dispensed, and not dispensed. |
Robert C Dieterle | Submitted on behalf of the Da Vinci Project | ||
| Draft USCDI V5 | 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 or screening for the presence of a mental or behavioral problem. Examples include but are not limited to Confusion Assessment Method (CAM) and Patient Health Questionnaire (PHQ). |
|
Michelle Dougherty | Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup | |
| Draft USCDI V5 | 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. Examples include but are not limited to pregnant, not pregnant, and unknown. |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Draft USCDI V5 | 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. |
SDOH Assessment |
Screening questionnaire-based, structured evaluation for a Social Determinants of Health-related risk. Examples include but are not limited to food, housing, and transportation security. |
|
Mark Savage for Gravity Project | Gravity Project | |
| Draft USCDI V5 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
SDOH Problems/Health Concerns |
Social Determinants of Health-related health concerns, conditions, or diagnoses. Examples include but are not limited to homelessness and food insecurity. |
|
Mark Savage for Gravity Project | Gravity Project | |
| Draft USCDI V5 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
SDOH Goals |
Desired future states for an identified Social Determinants of Health-related health concern, condition, or diagnosis. Examples include but are not limited to food security, transportation security, and ability to access health care. |
|
Mark Savage for Gravity Project | Gravity Project | |
| Draft USCDI V5 | Procedures | Activity performed for or on a patient as part of the provision of care. |
SDOH Interventions |
Actions or services to address an identified Social Determinants of Health-related health concern, condition, or diagnosis. Examples include but are not limited to education about food pantry program and referral to non-emergency medical transportation program. |
|
Mark Savage for Gravity Project | Gravity Project | |
| Draft USCDI V5 | Orders | Provider-authored request for the delivery of patient care services. |
Orders |
Provider-authored directive for the delivery of patient care services. Examples include but are not limited to diagnostic imaging, laboratory tests, interventions, referrals and consultations, and do-not-resuscitate. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Draft USCDI V5 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
Treatment Intervention Preference |
Person's goals, preferences, and priorities for care and treatment in case that person is unable to make medical decisions because of a serious illness or injury. Examples include but are not limited to thoughts on cardiopulmonary resuscitation, mental health treatment preferences, and thoughts on pain management. |
|
Matt Elrod on behalf of ADVault, Inc. | ADVault, Inc. | |
| Draft USCDI V5 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
Care Experience Preference |
Person's goals, preferences, and priorities for overall experiences during their care and treatment. Examples include but are not limited to religious beliefs, dislikes and fears, and thoughts and feelings to be shared. |
|
Matt Elrod on behalf of ADVault, Inc. | ADVault, Inc. | |
| Draft USCDI V5 | 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. |
Substance Use |
Evaluation of a patient's reported use of drugs or other substances for non-medical purposes or in excess of a valid prescription. Examples include but are not limited to substance use disorder score and substance use knowledge assessment. |
|
Jessica Cotto | National Institute on Drug Abuse | |
| Draft USCDI V5 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Author Role |
Category of actor that participated in the creation or revision of data. Examples include but are not limited to provider, patient, family member, and device. |
Gary Dickinson | EHR Standards Consulting | ||
| Draft USCDI V5 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Subscriber Identifier |
Sequence of characters used to uniquely refer to the individual that selects insurance benefits. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| Draft USCDI V5 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Payer Identifier |
Sequence of characters used to uniquely refer to an insurance payer. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| Draft USCDI V5 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Coverage Type |
Category of health care payers, insurance products, or benefits. Examples include but are not limited to Medicaid, commercial, HMO, Medicare Part D, and dental. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Draft USCDI V5 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Group Identifier |
Sequence of characters used to uniquely refer to a specific health insurance plan. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| Draft USCDI V5 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Result Status |
State or condition of a laboratory test. |
Maria Michaels | CDC | ||
| Draft USCDI V5 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Clinical Test |
Non-imaging or non-laboratory test. Examples include but are not limited to electrocardiogram (ECG), visual acuity exam, macular exam, and graded exercise testing (GXT). |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Draft USCDI V5 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Diagnostic Imaging Test |
Tests that generate visual images and require interpretation by qualified professionals. Examples include but are not limited to computed tomography-head, radiograph-chest, and ultrasound-pelvis. |
|
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee |