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 V5 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Adherence |
Statement of whether a medication has been consumed according to instructions. Examples include but are not limited to taking as directed, taking less than directed, and not taking. |
|
Shelly Spiro | Pharmacy HIT Collaborative | |
| USCDI V5 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Relationship to Subscriber |
Relationship of a patient to the primary insured person. |
Mark Roberts | Leavitt Partners | ||
| USCDI V5 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Coverage Status |
Presence or absence of healthcare insurance. |
Mark Roberts | Leavitt Partners | ||
| USCDI V5 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Tribal Affiliation |
Tribe or band with which an individual associates. |
Laura Conn | |||
| USCDI V5 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Result Interpretation |
Categorical assessment of a laboratory value, often in relation to a test's reference range. Examples include but are not limited to high, low, critical high, and normal. |
|
Riki Merrick | Association of Public Health Laboratories | |
| USCDI V5 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Identifier |
Sequence of characters assigned by a laboratory for an individual specimen. Example includes but is not limited to accession number. |
Riki Merrick | Association of Public Health Laboratories | ||
| 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. |
Alcohol Use |
Evaluation of a patient's consumption of alcohol. Examples include but are not limited to history of alcohol use, alcohol use disorder identification test, and alcohol intake assessment. |
|
Clem McDonald | National Library of Medicine | |
| USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Operative Note |
Narrative summary of a surgical procedure. Usage note: May include procedures performed, operative and anesthesia times, findings observed, fluids administered, specimens obtained, and complications identified. |
|
Leslie Kelly Hall | Engaging Patient Strategy | |
| USCDI V5 | Observations | Findings or other clinical data collected about a patient during care. |
Advance Directive Observation |
Information about a patient or provider authored document indicating its location, content, type, and verification status. Usage note: May include structured or unstructured data, whether a person has one or more advance directive documents, the type of advance directive, the location of the document, and whether it has been verified. Such documents may be used should a person be unable to communicate their wishes, preferences, or priorities to their provider. Examples include but are not limited to an indication that a living will is on file, a reference to the location of durable medical power of attorney, and the validating provider. |
Rachel Eager | New York eHealth Collaborative | ||
| USCDI V5 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Condition Acceptability |
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. |
|
Han Tran | College of American Pathologists (CAP) | |
| USCDI V5 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Result Reference Range |
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. |
|
Nedra Y Garrett | CDC | |
| USCDI V5 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Result Unit of Measure |
Unit of measurement to report quantitative laboratory test results. |
|
Nedra Y Garrett | CDC | |
| 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. |
Physical Activity Status |
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. |
|
Laurie P. Whitsel | American Heart Association/Physical Activity Alliance | |
| USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Emergency Department Note |
Narrative summary of care delivered in an emergency department. |
|
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) | |
| USCDI V5 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Route of Administration |
Physiological administration path of a therapeutic agent into or onto a patient. Examples include but are not limited to oral, topical, and intravenous. |
|
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) | |
| USCDI V5 | Immunizations | Record of vaccine administration. |
Lot Number |
Sequence of characters representing a specific quantity of manufactured material within a batch of a vaccine product. |
Sandi Mitchell | J P Systems, Inc. | ||
| USCDI V5 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Interpreter Needed |
Indication of whether a person needs language interpretation services. |
|
Scott Stare | CMS Office of Minority Health | |
| USCDI V5 | Orders | Provider-authored request for the delivery of patient care services. |
Laboratory Order |
Provider-authored request for the performance of a laboratory test. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V5 | Orders | Provider-authored request for the delivery of patient care services. |
Medication Order |
Provider-authored request for the dispensing of a therapeutic agent. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V5 | Orders | Provider-authored request for the delivery of patient care services. |
Diagnostic Imaging Order | Provider-authored request for the performance of a diagnostic imaging study. | Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) |