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 | Data used to categorize individuals for identification, records matching, and other purposes. |
Name that should be used when addressing or referencing the patient. Usage note: This information should be provided by the patient. Example includes but is not limited to nickname. |
Robert McClure, MD | HL7 International | ||||
| Draft USCDI V5 | Data used to categorize individuals for identification, records matching, and other purposes. |
Word or words that can replace a person’s name when addressing or referring to a person. Usage note: This information should be provided by the patient. Examples include but are not limited to she, her, they, them, he, his. |
Robert McClure, MD | HL7 International | ||||
| Draft USCDI V5 | Findings or other clinical data collected about a patient during care. |
Category based upon clinical observations typically associated with the designation of male and female. |
Robert McClure, MD | HL7 International | ||||
| Draft USCDI V5 | Narrative patient data relevant to the context identified by note types.
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Operative Note | Summary of a surgical procedure. Usage note: May include procedures performed, operative and anesthesia times, findings observed, fluids administered, specimens obtained, and complications identified. |
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Leslie Kelly Hall | Engaging Patient Strategy | ||
| Draft USCDI V5 | Findings or other clinical data collected about a patient during care. |
Statement of presence and properties of patient or provider authored documents that record a patient’s goals, preferences and priorities should a patient be unable to communicate them to a provider. Usage note: May include whether a person has one or more advance directives, the type of advance directive, the location of the current source document, and whether it has been verified. Examples include but are not limited to indication that a living will is on file, reference to or location of durable medical power of attorney, and validating provider. |
Rachel Eager | New York eHealth Collaborative | ||||
| Draft USCDI V5 | Analysis of clinical specimens to obtain information about the health of a patient. |
Information regarding a specimen, including the container, that does not meet a laboratory’s criteria for acceptability. Usage note: This may include information about the contents of the container, the container, and the label. Examples include but are not limited to hemolyzed, clotted, container leaking, and missing patient name. |
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Han Tran | College of American Pathologists (CAP) | |||
| Draft USCDI V5 | Analysis of clinical specimens to obtain information about the health of a patient. |
Upper and lower limit of quantitative test values expected for a designated population of individuals. Usage note: reference range values may differ by patient characteristics, laboratory test manufacturer, and laboratory test performer. |
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Nedra Y Garrett | CDC | |||
| Draft USCDI V5 | Analysis of clinical specimens to obtain information about the health of a patient. |
Unit of measurement to report quantitative laboratory test results. |
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Nedra Y Garrett | CDC | |||
| Draft USCDI V5 | 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. |
Evaluation of a patient's current or usual exercise. Examples include but are not limited to frequency of muscle-strengthening physical activity, days per week with moderate to strenuous physical activity, and minutes per day of moderate to strenuous physical activity. |
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Laurie P. Whitsel | American Heart Association/Physical Activity Alliance | |||
| Draft USCDI V5 | Narrative patient data relevant to the context identified by note types.
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Emergency Department Note |
Summary of care delivered in an emergency department. |
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Smitha Vellanky, on behalf of Joel Andress and Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Draft USCDI V5 | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Physiological administration path of a therapeutic agent into or onto a patient. Examples include but are not limited to oral, topical, and intravenous. |
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Smitha Vellanky, on behalf of Joel Andress and Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V5 | Record of vaccine administration. |
Lot Number |
Sequence of characters representing a specific quantity of manufactured material within a batch. |
Sandi Mitchell | J P Systems, Inc. | |||
| Draft USCDI V5 | Data used to categorize individuals for identification, records matching, and other purposes. |
Interpreter Needed |
Indication of whether a person needs language interpretation services. |
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Scott Stare | CMS Office of Minority Health | ||
| USCDI V5 | Patient Summary and Plan | Information that guides 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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| USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Consultation Note |
Narrative summary of care provided in response to a request from a clinician for an opinion, advice, or service. Examples include but are not limited to dermatology, dentistry, and acupuncture. |
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| USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Discharge Summary Note |
Narrative summary 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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| USCDI V5 | 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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| USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Procedure Note |
Narrative summary of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation. |
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| USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Progress Note |
Narrative 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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| USCDI V5 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
Patient Goals |
Desired outcomes of patient’s care. |