USCDI Export for the Public

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Classification Level Data Class Data Class Description Data Element Data Element Description Applicable Standards Submitter Name Submitter Organization Submission Date
USCDI V5 Care Team Members

Information about a person who participates or is expected to participate in the care of a patient.

 Care Team Member Telecom

Phone or email contact information for a care team member.
  • ITU-T E.123, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - General provisions concerning users: Notation for national and international telephone numbers, email addresses and web addresses (incorporated by reference in § 170.299)
  • ITU-T E.164, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - Numbering plan of the international telephone service: The international public telecommunication numbering plan
 Keith W. Boone Audacious Inquiry
USCDI V5 Encounter Information

Information related to interactions between healthcare providers and a patient.

 Encounter Location

Place where a patient’s care is delivered.
  • National Healthcare Safety Network (NHSN) Healthcare Facility Patient Care Location (HSLOC) Version 2022
  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2024 Release

 

 Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
USCDI V5 Encounter Information

Information related to interactions between healthcare providers and a patient.

 Encounter Identifier

Sequence of characters by which an encounter is known.

 Maria Michaels CDC
USCDI V5 Vital Signs

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

 Average Blood Pressure

Arithmetic average of systolic and diastolic components of two of more blood pressure readings in a specified time period or according to a specified algorithm or protocol.

Examples include but are not limited to 3-day morning and evening home monitoring, clinical encounter repeat average, and 24-hour ambulatory measurement.

Both standards are required.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.77
  • The Unified Code of Units for Measure, Revision 2.1
 Matt Reid American Medical Association
USCDI V5 Allergies and Intolerances

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

 Non-Medication Allergy Intolerance

Non-pharmacologic agent believed to cause a harmful or undesired physiologic response following exposure.

Examples include but are not limited to latex, eggs, pollen, and peanuts.
  • SNOMED Clinical Terms (SNOMED CT®) U.S. Edition, March 2024 Release
 John D'Amore Diameter Health
USCDI V5 Procedures

Activity performed for or on a patient as part of the provision of care.

 Performance Time

Time and/or date a procedure is performed.

Examples include but are not limited to vaccine or medication administration times, surgery start time, and time ultrasound performed.

 Sheila Abner CDC/NHSN
USCDI V5 Medications

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

 Dose Unit of Measure

Unit of measure of a medication.

Examples include but are not limited to milligram (mg) and milliliter (mL).
  • The Unified Code for Units of Measure, Revision 2.1
 Maria Michaels CDC
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.
  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2024 Release
  • International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 2024
 Maria Michaels CDC
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
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).
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.77
 Michelle Dougherty Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup
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)
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.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.77
  • SNOMED Clinical Terms (SNOMED CT®) U.S. Edition, March 2024 Release
 Mark Savage for Gravity Project Gravity Project
USCDI V5 Problems

Condition, diagnosis, or reason for seeking medical attention.

 SDOH Problems/Health Concerns

Social Determinants of Health-related concerns, conditions, or diagnoses.

Examples include but are not limited to homelessness and food insecurity.
  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2024 Release
  • International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 2024
 Mark Savage for Gravity Project Gravity Project
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 state for an identified Social Determinants of Health-related concern, condition, or diagnosis.

Examples include but are not limited to food security, transportation security, and ability to access healthcare.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.77
  • SNOMED Clinical Terms (SNOMED CT®) U.S. Edition, March 2024 Release
 Mark Savage for Gravity Project Gravity Project
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 concern, condition, or diagnosis.

Examples include but are not limited to education about food pantry program and referral to non-emergency medical transportation program.
  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2024 Release
  • Current Procedural Terminology (CPT®) 2024, as maintained and distributed by the American Medical Association, for physician services and other healthcare services
  • Healthcare Common Procedure Coding System (HCPCS) Level II, as maintained and distributed by HHS
 Mark Savage for Gravity Project Gravity Project
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.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.77
 Matt Elrod on behalf of ADVault, Inc. ADVault, Inc.
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.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.77
 Matt Elrod on behalf of ADVault, Inc. ADVault, Inc.
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.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.77
 Jessica Cotto National Institute on Drug Abuse
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.

Usage note: The source of the information can be used to form assessments about its quality, reliability, trustworthiness, or can indicate where to go to determine the origins of the information.

Examples include but are not limited to provider, patient, family member, and device.

 Gary Dickinson EHR Standards Consulting
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