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 V6 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Sequence of characters used to uniquely refer to an individual with respect to their insurance. |
Robert C Dieterle | On behalf of the Da Vinci Project | |||
| USCDI V6 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Findings of clinical tests. |
Melissa Ayres | SSA | |||
| USCDI V6 | 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. |
Assessment of a person’s ability to perform activities of daily living and activities across other situations and settings. Examples include but are not limited to Functional Assessment Standardized Items (FASI) and Timed Up and Go (TUG). |
|
Holly Miller, MD | MedAllies | ||
| USCDI V6 | 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. |
Assessment of a patient’s physical, cognitive, or psychiatric disabilities. Examples include but are not limited to American Community Survey, Veterans RAND Health Survey, and Patient-Reported Outcomes Measurement Information System (PROMIS). |
|
Grace Cordovano | Enlightening Results | ||
| USCDI V6 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Instructions |
Directions for administering or taking a medication. Usage note: May include route, quantity, timing/frequency, and special instructions (PRN, sliding scale, taper). Examples include but are not limited to prescription directions for taking a medication, and package instructions for over-the-counter medications. |
Shelly Spiro | Pharmacy HIT Collaborative | ||
| USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Type of business that compensates for work or assigns work to an unpaid worker or volunteer. Examples include but are not limited to U.S. Army, cement manufacturing, and children and youth services. |
|
Nedra Garrett | CDC | ||
| USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Type of work of a person. Examples include but are not limited to infantry, business analyst, and social worker. |
|
Nedra Garrett | CDC | ||
| USCDI V6 | 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 V6 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Relationship of a patient to the primary insured person. |
Mark Roberts | Leavitt Partners | |||
| USCDI V6 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Presence or absence of healthcare insurance. |
Mark Roberts | Leavitt Partners | |||
| USCDI V6 | Orders | 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. |
Portable Medical Order |
Provider-authored request for end-of-life or life-sustaining care for a person who has a serious life-limiting medical condition. Usage note: These are meant to follow a person regardless of when and where such an order might be needed (e.g., hospital, care facility, community, home). There are variations in requirements and names for portable medical orders based on jurisdiction. Examples include but are not limited to POLST (Portable Medical Order for Life-Sustaining Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and out-of-hospital DNR (do-not-resuscitate). |
Grace Glennon on behalf of Joel Andress and CMS-CCSQ | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Tribe or band with which an individual associates. |
Laura Conn | ||||
| USCDI V6 | 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 V6 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
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 V6 | 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. |
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 V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
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 V6 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
Advance Directive Observation |
Information about a patient or provider authored document indicating its location, content, type, and verification status.
|
Rachel Eager | New York eHealth Collaborative | ||
| USCDI V6 | Care Plan | Information that guides treatment of the patient and recommendations for future treatment. |
Shared plan informed by members of a coordinated care team that details conditions, needs, and goals along with strategies for addressing them. Usage notes: Includes problems, health concerns, assessments, goals, and interventions from across care settings. Examples include but are not limited to clinical care plans, condition-specific care plans, coordinated care plan. |
Julia Skapik | NACHC | |||
| USCDI V6 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Condition Acceptability |
Information about a specimen, including the container, that is used to determine 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 V6 | 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 |