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 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Progress Note | Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
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| USCDI V2 | Goals | Desired state to be achieved by a patient. |
Patient Goals | Desired outcomes of patient's care. |
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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. |
Assessment and Plan of Treatment | |||||
| Level 2 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Device used | Devices are an identifiable grouping of mobility devices (i.e., wheelchairs), implantable devices (i.e., pace makers), or other wearable devices (i.e. compression socks or venous foot pump) with significant impact on patient functionality and health. The QDM v5.5 notes that “Device represents an instrument, apparatus, implement, machine, contrivance, implant, in-vitro reagent, or other similar or related article, including a component part or accessory, intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease and not dependent on being metabolized to achieve any of its primary intended purposes.” |
SNOMED CT (Frailty Device, value set OID: 2.16.840.1.113883.3.464.1003.118.12.1300) SNOMED CT (Intermittent Pneumatic Compression Devices (IPC), value set OID: 2.16.840.1.113883.3.117.1.7.1.214) SNOMED CT (Graduated Compression Stockings (GSC), value set OID: 2.16.840.1.113883.3.117.1.7.1.256) SNOMED CT (Venous Foot Pumps (VFP), value set OID: 2.16.840.1.113883.3.117.1.7.1.230) SNOMED CT (Cardiac Pacer, value set OID: 2.16.840.1.113883.3.526.3.1193) ICD-10-CM, SNOMED CT (Cardiac Pacer in Situ, value set OID: 2.16.840.1.113883.3.526.3.368) |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Level 2 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Product Code | Provides a description of and supports traceability for a product |
ISBT-128 Product Description Code |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Policy Number | The unique identifier for a specific insurance policy that defines a set of covered benefits and services along with other information that is necessary to administer the policy (e.g. financial obligations for both parties) |
Member, subscriber, group, and plan identifiers are assigned by healthcare insurer. The coverage period is a standard date range during which the coverage is in effect. There is currently no standard Healthcare Payer Identifier (e.g. HPID) but frequently the NAIC identifier is used but not required. |
Robert C Dieterle | On behalf of the Da Vinci Project | |
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Coverage Period | The time frame in which the policy is in force. |
Member, subscriber, group, and plan identifiers are assigned by healthcare insurer. The coverage period is a standard date range during which the coverage is in effect. There is currently no standard Healthcare Payer Identifier (e.g. HPID) but frequently the NAIC identifier is used but not required. |
Robert C Dieterle | On behalf of the Da Vinci Project | |
| Level 2 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Medical Device Status | Information beyond the UDI is required for patient care and clinical research. If a patient record is transferred to a new provider, the implant date of all active and inactive devices as well as the explant date of previously implantable devices is relevant. To conduct safety and effectiveness research, implant date, explant date and therapy status are relevant. Proposing implanted/inactivated/reactivated/explanted as the status values and that the status history is included as opposed to only current status. | NCI Thesaurus |
TICIA Louise GERBER | Health Level Seven International | |
| Level 2 | Social History | Sexual Activity | Information on the sexual activity of the patient |
SNOMED CT: (Parent code and all children codes in the hierarchy) 414254005 - Finding of frequency of sexual activity (finding) 162171002 - Currently not sexually active (finding) 228453005 - Sexually active (finding) *LOINC 64728-9 - Have you ever had vaginal intercourse [PhenX] *Note Montana's Department of Public Health and Human Services (DPHHS) includes SNOMED CT codes in their “Adolescent Wellness” Registry, addressing the “STI Screening” measure, together with the “Chlamydia Screening in Women” measure. |
Raymonde Uy | National Association of Community Health Centers (NACHC) | ||
| Level 2 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Criticality | Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance. |
HL7 FHIR R4 Allergy Intolerance Criticality, Rx Norm, SNOMED CT, National Drug Code (NDC) |
Sandi Mitchell | J P Systems, Inc. | |
| Level 2 | 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. |
Medical Device Orders | Provider-authored request for medical devices, such as for therapeutic footwear or walking aids. |
SNOMED CT |
Grace Glennon, on behalf of NCQA | NCQA | |
| Level 2 | 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. |
Referral Orders | Provider-authored request to another provider, specialist, or organization for care services. Examples include referral orders to a wound specialist or podiatrist. |
SNOMED CT |
Grace Glennon, on behalf of NCQA | NCQA | |
| Level 2 | 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. |
Nutrition Order | A clinician (provider)-authored request for a diet, formula feeding (enteral), or nutritional supplement. |
SNOMED CT |
Michelle Ashafa | Academy of Nutrition and Dietetics | |
| Level 2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Accession Number | A unique identifier created by a departmental information system which identifies the Imaging Service Request. The Accession Number links the scheduled procedure, images, and their resulting diagnostic imaging report, created by the radiologist, back to the original order, supporting both clinical workflow and billing. The Accession Number may group one or more Requested Procedures. |
LOINC/RSNA Radiology Playbook includes Diagnostic Imaging Procedure Codes and Descriptions. |
Brian Bialecki | American College of Radiology | |
| Level 2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Imaging Reference | The technical details of the retrieval access path to indicate network services that can be used to access DICOM studies, series, or instances content and metadata (e.g., a DICOMweb server endpoint providing QIDO-RS, WADO-RS, or WADO-URI). |
LOINC/RSNA Radiology Playbook includes Diagnostic Imaging Procedure Codes and Descriptions. HL7 Standard for CDA® Release 2: Imaging Integration; Basic Imaging Reports in CDA and DICOM Release 1 references LOINC® Document Type Codes, SNOMED CT® Quantity Measurement Type Codes, as well as DICOM Code Systems. FHIR ImagingStudy references SNOMED CT Body Structures |
Brian Bialecki | American College of Radiology | |
| Level 2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Deceased Indicator | Indicates if the individual is deceased or not. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 2 | Facility Information | Physical place of available services or resources. |
Facility Contact Information | Various: FHIR DSTU2, 3 and 4, CDA Release 2.0, HL7 V2 PL Data Type |
Keith W. Boone | Audacious Inquiry | ||
| Level 2 | Organization | Healthcare Services | Describe a specific healthcare service or category of services (such as counseling, imaging, or laboratory) offered by an organization at a designated location, which can be either physical or virtual. The service provider may include hospitals, clinics, pharmacies, or other specialized healthcare providers. |
In addition to LOINC and SNOMED CT, other relevant code systems for the Healthcare Service data element include: 1. NDC (National Drug Code): For identifying medications and drug services. These additional code systems further support the standardized representation of healthcare services. |
Mike Hamidi | Vulcan | ||
| Level 2 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
UDI-Production Identifier-Manufacturing Date or UDI-PI-Manufacturing Date | The date on which a device is manufactured. Taken from FDA Data Elements Reference Table - see https://www.fda.gov/media/88408/download |
Please see FDA UDI regulation and FDA Data Elements Reference Table - see https://www.fda.gov/media/88408/download. Please see FDA Formats by Accredited Issuing Agency that shows the structured of each of the parts of the UDI as a complete standard - https://www.fda.gov/media/96648/download UDI-DI and all AccessGUDID data elements are listed in NCI Thesaurus. See https://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/NCI_FDA/index.html#:~:text=%20The%20NCI%20Thesaurus%20includes%20the%20following%20FDA,Global%20Unique%20Device%20Identification%20Database%20%28GUDID%29%20More%20 |
Terrie Reed | Symmetric Health Solutions | |
| Level 2 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
UDI-Production Identifier-Lot or UDI-PI-Lot | The number assigned to one or more device(s) that consists of a single type, model, class, size, composition, or software version that are manufactured under essentially the same conditions and that are intended to have uniform characteristics and quality within specified limits. Taken from FDA Data Elements Reference Table - see https://www.fda.gov/media/88408/download |
Please see FDA UDI regulation and FDA Data Elements Reference Table - see https://www.fda.gov/media/88408/download. Please see FDA Formats by Accredited Issuing Agency that shows the structured of each of the parts of the UDI as a complete standard - https://www.fda.gov/media/96648/download UDI-DI and all AccessGUDID data elements are listed in NCI Thesaurus. See https://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/NCI_FDA/index.html#:~:text=%20The%20NCI%20Thesaurus%20includes%20the%20following%20FDA,Global%20Unique%20Device%20Identification%20Database%20%28GUDID%29%20More%20 |
Terrie Reed | Symmetric Health Solutions |