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 V6 | 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. | |||
| Draft USCDI V6 | 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 | ||
| Draft USCDI V6 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the performance of a laboratory test. |
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Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V6 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Medication Order |
Provider-authored request for the dispensing of a therapeutic agent. |
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Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Draft USCDI V6 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Diagnostic Imaging Order |
Provider-authored request for the performance of a diagnostic imaging study. |
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Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Draft USCDI V6 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Procedure Order |
Provider-authored request for the performance of a diagnostic or therapeutic intervention. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V6 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Clinical Test Order |
Provider-authored request for the performance of a non-laboratory or non-imaging test. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Draft USCDI V6 | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Unique Device Identifier (UDI) |
Numeric or alphanumeric code that uniquely identifies a medical device. Usage note: Contains a device identifier (DI) and one or more production identifiers (PI). |
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Marti Velezis | FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII) | ||
| USCDI V3 | Assessment and Plan of Treatment | Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
Assessment and Plan of Treatment |
Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
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| USCDI V3 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Consultation Note |
Response to request from a clinician for an opinion, advice, or service from another clinician. |
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| USCDI V3 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Discharge Summary Note |
Synopsis of a patient’s admission and course in a hospital or post-acute care setting. Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization. |
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| USCDI V3 | 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. (e.g., admission, surgery, or other procedure) |
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| USCDI V3 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Procedure Note |
Synopsis of non-operative procedures. (e.g., interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation) |
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| USCDI V3 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Progress Note |
Summary of a patient’s interval status during an encounter. (e.g., hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter) |
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| USCDI V3 | Goals | Desired state to be achieved by a patient. |
Patient Goals |
Desired outcomes of patient’s care. |
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| USCDI V3 | 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. |
Health Concerns |
Health-related issue or worry. (e.g., weight gain, cancer risk) |
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| USCDI V3 | Immunizations | Record of vaccine administration. |
Immunizations |
Vaccine product administered, planned, or reported. |
Both standards are required
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| USCDI V3 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Tests |
Analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health. |
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| USCDI V3 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Values/Results |
Documented findings of a tested specimen including structured and unstructured components. |
Both standards are required:
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| USCDI V3 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medications |
Pharmacologic agent used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Optional:
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