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.

Suffix
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.

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 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 Care Team Members

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

Care Team Member Name 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
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
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
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 Care Team Members

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

Care Team Member Role

Function or functions that a person may perform while participating in the care for a patient

Al Taylor ONC
USCDI V2 Patient Demographics/Information

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

Middle Name (including middle initial)
USCDI V2 Procedures

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

Procedures
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • Current Procedural Terminology (CPT®) 2021, as maintained and distributed by the American Medical Association, for physician services and other health care services, and Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by HHS.
  • For technology primarily developed to record dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services.

Optional:

  • International Classification of Diseases ICD-10-PCS 2021
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. 
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 2.70

  • Consult Note (LOINC® code 11488-4)
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.

Swapna Abhyankar Regenstrief Institute, LOINC Document Ontology Subcommittee
USCDI V2 Patient Demographics/Information

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

First Name
USCDI V2 Vital Signs

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

Systolic Blood Pressure

Both standards are required.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V2 Procedures

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

SDOH Interventions

A service offered to a patient to address identified Social Determinants of Health concerns, problems, or diagnoses (e.g., Education about Meals on Wheels Program, Referral to transportation support programs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes.

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • Current Procedural Terminology (CPT®) 2021, as maintained and distributed by the American Medical Association, for physician services and other health care services
  • Healthcare Common Procedure Coding System (HCPCS) Level II, as maintained and distributed by HHS
Mark Savage for Gravity Project Gravity Project
USCDI V2 Patient Demographics/Information

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

Last Name
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.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
USCDI V2 Provenance

The metadata, or extra information about data, regarding who created the data and when it was created.

Author Time Stamp
USCDI V2 Vital Signs

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

Body Weight
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
  • The Unified Code of Units for Measure (UCUM), Revision 2.1