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 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Author Time Stamp | |||||
| USCDI V2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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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
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| 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.
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| USCDI V2 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Procedures |
Optional:
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| USCDI V2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Body Weight |
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| 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. |
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Mark Savage for Gravity Project | Gravity Project | |
| 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. |
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| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Last Name | |||||
| USCDI V2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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History & Physical | Documents the current and past conditions and observations of the patient. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
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| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Previous Name | |||||
| USCDI V2 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Problems |
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| USCDI V2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Body Temperature |
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| USCDI V2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Respiratory Rate |
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| USCDI V2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Heart Rate |
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| USCDI V2 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Location | Location of facility which delivered a person’s health care or related services |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V2 | Goals | Desired state to be achieved by a patient. |
SDOH Goals | Identifies a future desired condition or change in condition related to an SDOH risk in any domain and is established by the patient or provider. (e.g., Has adequate quality meals and snacks, Transportation security-able to access health and social needs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. |
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Mark Savage for Gravity Project | Gravity Project | |
| USCDI V2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Pulse Oximetry |
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| USCDI V2 | Assessment and Plan of Treatment | Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
SDOH Assessment |
Structured evaluation of risk (e.g., PRAPARE, Hunger Vital Sign, AHC-HRSN screening tool) for any Social Determinants of Health domain such as food, housing, or transportation security. SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. |
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Mark Savage for Gravity Project | Gravity Project |